Nursing Elites

1. The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately?

• A. Swollen and discolored penile shaft
• B. Prepuce extends over the head of the penis
• C. Leaking urine around the top of the catheter
• D. Moist and excoriated perineal skin folds

Correct answer: A

Rationale: The correct answer is A: Swollen and discolored penile shaft. Swelling and discoloration of the penile shaft may indicate an infection or other complications requiring immediate attention. Prompt reporting allows for timely intervention to prevent further harm to the client. Choice B is incorrect because the prepuce extending over the head of the penis is not an urgent issue. Choice C, leaking urine around the catheter, may require intervention but is not as urgent as the swelling and discoloration described in choice A. Choice D, moist and excoriated perineal skin folds, also needs attention but is not as concerning as the potential complications indicated by the findings in choice A.

2. The nurse assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the nurse provide the UAP?

• A. Assist the client with a hot bath
• B. Encourage self-care but allow rest periods
• C. Face the client directly when speaking
• D. Keep the head of the bed elevated at all times

Correct answer: B

Rationale: The correct instruction for the UAP to provide when assisting a client experiencing an acute exacerbation of multiple sclerosis is to encourage self-care but allow rest periods. Clients with multiple sclerosis often experience fatigue, so promoting self-care activities while ensuring they have adequate rest periods is crucial for symptom management and maintaining independence. Choice A is incorrect as hot baths can potentially exacerbate symptoms in clients with multiple sclerosis. Choice C is unrelated to the client's care needs during an acute exacerbation of multiple sclerosis. Choice D is not a priority instruction in this situation and may not directly impact the client's immediate care needs.

3. In a group therapy setting, one member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse's best response would be:

• A. Will you briefly summarize your point because others need time as well?
• B. Your behavior is obnoxious and drains the group.
• C. I am so frustrated with your behavior.
• D. To ignore the behavior and allow him to vent

Correct answer: A

Rationale: In a group therapy setting, where each member should have the opportunity to participate, it is essential for the nurse to manage disruptive behavior assertively yet respectfully. Choice A is the best response as it addresses the issue of one member dominating the group time by asking them to summarize their point briefly, allowing others to contribute. Choice B is confrontational and may alienate the individual, hindering the therapeutic process. Choice C expresses personal frustration, which is not constructive in managing the situation. Choice D of ignoring the behavior is not effective as it allows the disruptive behavior to continue, impacting the group dynamics negatively.

4. The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?

• A. Ask her to share how the injury occurred to her child.
• B. Recommend that she remain calm and positive for her child.
• C. Express that the present situation must be overwhelming.
• D. Determine if someone else can help her cope with this tragedy.

Correct answer: C

Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.

5. In which stage of Maslow's hierarchy of needs is a young adult attempting to achieve when deciding to change his work hours to devote more time to his community?

• A. Self-Actualization
• B. Intimacy vs. Isolation
• C. Altruism
• D. Purposefulness

Correct answer: A

Rationale: The correct answer is A: Self-Actualization. The young adult is striving for self-actualization, the highest level in Maslow's hierarchy of needs. Self-actualization is characterized by individuals seeking personal growth, self-fulfillment, and the ability to contribute to society. Choice B, Intimacy vs. Isolation, focuses on relationships and occurs at a different stage. Choice C, Altruism, although related to community contribution, does not specifically address personal growth and fulfillment as in self-actualization. Choice D, Purposefulness, is not a stage in Maslow's hierarchy of needs and is not directly relevant to the scenario described.

Similar Questions