Nursing Elites

1. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?

• A. Physical therapy for muscle strengthening exercises
• B. Physical therapy for range of motion exercises
• C. Occupational therapy to help her with confusion
• D. Medications to help her sleep more

Correct answer: A

Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.

2. When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?

• A. Ensure the safety belt or strap is secured on the patient while escorting them to the operating room
• B. Use a safety belt or strap on the patient throughout their escort to the operating room
• C. Lower the bed position when moving the patient from the bed to the stretcher
• D. All of the above options are correct

Correct answer: B

Rationale: When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.

3. A client in a long-term care facility tells the nurse, 'My daughter never visits me.' The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?

• A. Empathy
• B. Self-disclosure
• C. Disapproval
• D. False reassurance

Correct answer: B

Rationale: Self-disclosure is a therapeutic communication technique that nurses use to build rapport and trust with clients. By sharing personal experiences, nurses can help clients feel understood and encourage them to open up. In this scenario, the nurse sharing her own struggle with visiting her mother demonstrates self-disclosure. Empathy (choice A) involves understanding and sharing the feelings of another, but in this case, the nurse is sharing her own experience rather than focusing solely on the client's emotions. Disapproval (choice C) and false reassurance (choice D) do not apply in this context as the nurse is not expressing disapproval or giving false hope or comfort.

4. Which of the following situations warrants a measurement for orthostatic hypotension?

• A. A 36-year-old male with a spinal injury
• B. An 86-year-old female with significantly altered mental status
• C. A 58-year-old female with near-syncope
• D. A 41-year-old male with acute deep vein thrombosis

Correct answer: C

Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.

5. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?

• A. Let them talk to another patient who has had the same therapy
• B. Provide research-based information about therapeutic hypothermia
• C. Connect them with the nurse manager
• D. Call the physician and ask him to talk to the family

Correct answer: B

Rationale: Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.

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