Nursing Elites

1. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

• A. Mrs. Guevarra makes the assignment to instruct the staff member
• B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
• C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
• D. Mrs. Guevarra must know how to perform the task being delegated

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

2. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?

• A. This is a normal, expected reaction for a child of this age.
• B. This is a response to an overstimulating environment.
• C. This is a common reaction to an overexposure to caregivers.
• D. This is a typical reaction for a child who is sick.

Correct answer: A

Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.

3. Protein-energy malnutrition (PEM) may be responsible for the increased incidence of noma and necrotizing ulcerative gingivitis (NUG) because these conditions are associated with depressed immune responses caused by nutritional deficiencies.

• A. Both the statement and the reason are correct and related
• B. Both the statement and the reason are correct but are not related
• C. The statement is correct, but the reason is not correct
• D. The statement is not correct, but the reason is correct

Correct answer: A

Rationale: The corrected question highlights that protein-energy malnutrition weakens the immune system, making individuals more susceptible to conditions like noma and NUG, which are linked to compromised immunity. Choice A is correct because the statement and reason are both accurate and directly related. Protein-energy malnutrition does result in depressed immune responses, which can predispose individuals to noma and NUG. Choice B is incorrect because the statement and reason are indeed related. Choice C is incorrect as both the statement and reason are accurate. Choice D is also incorrect as the statement is correct and directly supports the reason provided.

4. The purpose of ECT in clients with depression is to:

• A. Stimulation in the brain to increase brain conduction and counteract depression
• B. Mainly Biologic, increasing the norepinephrine and serotonin level
• C. Creates a temporary brain damage that will increase blood flow to the brain
• D. Involves the conduction of electrical current to the brain to charge the neurons and combat depression

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

5. Gina, A client in prolong labor said she cannot go on anymore. The health care team decided that both the child and the mother cannot anymore endure the process. The baby is premature and has a little chance of surviving. Caesarian section is not possible because Gina already lost enough blood during labor and additional losses would tend to be fatal. The husband decided that Gina should survive and gave his consent to terminate the fetus. The principle that will be used by the health care team is:

• A. Beneficence
• B. Non malfeasance
• C. Justice
• D. Double effect

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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