Nursing Elites

1. The PN is caring for an older client who was informed about the diagnosis of terminal cancer two days ago. Which intervention would be most helpful for the client's spouse at this time?

• A. Consultation with the case manager and hospital chaplain
• B. Visiting after procedures are done to avoid seeing the client in pain
• C. Participating in the client's care within his/her capabilities and desires
• D. Information about palliative and hospice care services

Correct answer: D

Rationale: Providing information about palliative and hospice care services can help the spouse understand the options for managing the client's symptoms and improving the quality of life. This also provides support and guidance during a difficult time. Consulting with the case manager and hospital chaplain may be beneficial for emotional support but may not address the practical aspects of care. Visiting after procedures are done to avoid seeing the client in pain may not foster open communication and support. While participating in the client's care is important, providing information about palliative and hospice care services is the most helpful intervention in this scenario.

2. A female Native American client who is receiving chemotherapy places a native artifact, an Indian medicine wheel, in her hospital room. The HCP removes the medicine wheel and tells the client, 'This type of thing does not belong in the hospital.' Which intervention should the PN implement?

• A. Teach the client about the importance of adhering to the chemotherapy regimen
• B. Act as the client's advocate when addressing the issue with the HCP
• C. Consult with a Native American healer about the appropriate use of a medicine wheel
• D. Inform the HCP about the client's feelings of culture shock

Correct answer: B

Rationale: Acting as the client's advocate is the most appropriate intervention in this situation. Removing a culturally significant artifact without considering the client's beliefs and emotional needs can be distressing. By advocating for the client, the PN can ensure that the client's cultural practices are respected, which is crucial for her emotional and spiritual well-being during treatment. Choice A is incorrect because while chemotherapy adherence is important, it is not the most immediate concern in this scenario. The client's cultural needs and well-being take precedence. Choice C is incorrect because consulting with a Native American healer might not be necessary at this point and could delay addressing the immediate issue of advocating for the client's rights. Choice D is incorrect because simply reporting the client's feelings of culture shock to the HCP does not actively address the situation or advocate for the client's rights and cultural needs.

3. What disorder closely matches Suzy's symptoms?

• A. Antisocial personality disorder
• B. Borderline personality disorder
• C. Schizoid personality disorder
• D. Dissociative Identity Disorder

Correct answer: B

Rationale: Suzy's symptoms are characteristic of Borderline Personality Disorder (BPD). BPD includes instability in relationships, self-image, and emotions, as well as impulsivity and self-harm. Choice A, Antisocial personality disorder, is characterized by a disregard for others' rights and lack of empathy, which does not align with Suzy's symptoms. Schizoid personality disorder, choice C, is characterized by a lack of interest in social relationships, which is not a prominent feature in Suzy's case. Dissociative Identity Disorder, choice D, involves the presence of two or more distinct identities or personality states, which is not reflected in Suzy's symptoms.

4. When documenting information in a client's medical record, what should the nurse do?

• A. Cross out errors with a single line and initial them
• B. Use a black ink pen
• C. Leave one line blank before each new entry
• D. End each entry with the nurse's signature and title

Correct answer: D

Rationale: When documenting information in a client's medical record, the nurse should end each entry with their signature and title. This practice is crucial for legal and professional standards compliance as it ensures that the documentation is attributable to the responsible individual. Choices A, B, and C are incorrect because while crossing out errors, using a black ink pen, and leaving a blank line before each entry are good practices, they are not as critical as ensuring each entry is signed and titled by the nurse for accountability and traceability.

5. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?

• A. Impaired verbalization
• B. Depressed mood
• C. Flat affect
• D. Diminished LOC

Correct answer: C

Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.

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