Nursing Elites

1. Which action by the novice nurse indicates a need for further teaching?

• A. The nurse fails to wear gloves when removing a dressing.
• B. The nurse applies an oxygen saturation monitor to the earlobe.
• C. The nurse elevates the head of the bed to check blood pressure.
• D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.

Correct answer: A

Rationale: The correct answer is A. The novice nurse failing to wear gloves when removing a dressing indicates a need for further teaching to emphasize infection control practices. This action can lead to the spread of infections. Choices B, C, and D are incorrect because they demonstrate proper nursing skills and techniques. Applying an oxygen saturation monitor to the earlobe, elevating the head of the bed to check blood pressure, and placing the extremity in a dependent position to acquire a peripheral blood sample all reflect understanding of correct procedures in patient care.

2. When teaching clients with a diagnosis of Schizophrenia nearing discharge from a residential care facility, what is an essential topic to include?

• A. pathophysiology of the disease and expected symptoms.
• B. how to recognize and manage symptoms of relapse.
• C. the need to take extra medication when feeling stressed.
• D. the importance of contact with follow-up care daily.

Correct answer: B

Rationale: When educating clients with Schizophrenia nearing discharge, it is crucial to focus on teaching them how to recognize and manage symptoms of relapse. Clients are usually aware of these symptoms, such as feeling anxious and overwhelmed, before the onset of psychosis. This early stage is vital for intervention, which involves finding a safe environment, seeking help, avoiding stressors, and reducing stimuli. Understanding and managing relapse symptoms empower clients to take proactive steps in their care. Choices A and C are not as immediate and practical as recognizing symptoms of relapse for client safety and well-being. While contact with follow-up care is important, it is not as urgent and specific as knowing how to manage relapse symptoms for immediate intervention.

3. The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?

• A. Rationalization
• B. Denial
• C. Projection
• D. Conversion reaction

Correct answer: B

Rationale: The correct answer is B: Denial. The client displaying denial refuses to acknowledge the reality of having a myocardial infarction. Rationalization (choice A) involves making excuses for behavior, not denying a condition. Projection (choice C) is attributing one's thoughts or feelings to others, not denying an illness. Conversion reaction (choice D) is converting psychological distress into physical symptoms, which is not evident in this scenario. Therefore, denial is the defense mechanism being used in this situation.

4. The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:

• A. Have decreased anxiety.
• B. Talk to the nurse for 10 minutes.
• C. Sit quietly for 30 minutes.
• D. Develop an adaptive coping mechanism.

Correct answer: B

Rationale: When developing outcome criteria for a client with severe anxiety, it is crucial for the goals to be specific, measurable, and realistic. In this scenario, the most appropriate outcome is for the client to talk to the nurse for 10 minutes within 4 days. This goal is specific (talking for a defined duration), measurable (10 minutes), and realistic given the client's condition. Expecting a severely anxious client to sit quietly for 30 minutes is not realistic and may even exacerbate their anxiety. While developing an adaptive coping mechanism is important, it is a broader long-term goal and may not be achievable within the specified timeframe. Having decreased anxiety is a desirable outcome, but it lacks specificity and measurability, making it less suitable as an immediate goal.

5. The best definition of communication is:

• A. the sending and receiving of messages.
• B. the effect of sending verbal messages.
• C. an ongoing, interactive form of transmitting transactions.
• D. the use of message variables to send information.

Correct answer: C

Rationale: Communication is defined as an ongoing, interactive form of transmitting transactions. It involves a dynamic process of sending (encoding) and receiving (decoding) messages while being influenced by the experiences and perceptions of both the sender and receiver. This process is interactive and occurs within an environment, shaping individuals' self-concept, identity, and relationships. The correct answer captures the complexity and interactive nature of communication. Choice A, 'the sending and receiving of messages,' is too simplistic and does not encompass the interactive nature of communication. Choice B, 'the effect of sending verbal messages,' focuses solely on verbal communication and overlooks non-verbal forms. Choice D, 'the use of message variables to send information,' emphasizes technical aspects rather than the interactive and transactional nature of communication.

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