Nursing Elites

1. What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?

• A. Suggest that the client requesting attention speak with another staff member.
• B. Leave the new client, saying, 'I'll talk with the other client until things calm down.'
• C. Introduce the two clients and suggest that the client join them on a tour of the facility.
• D. Say to the interrupting client, 'I'll be back to talk with you after I orient this new client.'

Correct answer: D

Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client. Therefore, the correct approach is to say to the interrupting client, 'I'll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries. Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.

2. A new mother with class II heart disease tells the nurse that she is afraid her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond?

• A. Suggest that the client arrange for help at home
• B. Ask the client to describe her concerns more fully
• C. Tell the client to speak to her primary health care provider about her concerns
• D. Recommend that the client schedule times when family members can assist her

Correct answer: B

Rationale: When a client expresses fear or concern, it is essential for the nurse to first explore and understand the client's feelings and worries. Asking the client to describe her concerns more fully allows the nurse to gather more information, which is crucial in providing appropriate support and guidance. Suggesting that the client arrange for help at home is presumptuous and may not align with the client's preferences or resources. Telling the client to speak to her primary health care provider shifts the responsibility and does not directly address the client's immediate fears. Recommending that she schedule times when family members can assist her assumes the availability and willingness of family members without addressing the client's emotional needs and fears directly.

3. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

• A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
• B. Instruct the UAP not to wake the client under any circumstances during the night.
• C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
• D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Correct answer: A

Rationale: By determining the client's usual bedtime routine and incorporating these rituals into the care plan, the nurse can help the client fall asleep faster and improve the quality of care without compromising safety. This approach respects the client's individual needs and preferences. In contrast, options B, C, and D do not address the client's sleep issue effectively and may even compromise the client's safety or standard of care. Option B fails to address the underlying problem of the client's sleep disturbance, while option C reduces the frequency of assessments, which can impact the timely identification of changes in the client's condition. Option D focuses on pain medication and daytime napping, which are not directly related to the client's current sleep difficulties.

4. A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client's reaction?

• A. Reflection
• B. Regression
• C. Repudiation
• D. Reconciliation

Correct answer: C

Rationale: The client's reaction of believing that only minor surgery is necessary when faced with the need for an abdominoperineal resection and a colostomy is an example of repudiation. Repudiation involves a refusal to acknowledge anticipated loss as a defense mechanism against the overwhelming stress of illness. The client is psychologically denying the seriousness of the situation. The other choices are incorrect because: - Reflection (Choice A) does not apply since the client is not contemplating the issues of the situation. - Regression (Choice B) is not demonstrated as the client's behavior does not indicate reverting to an earlier stage of development. - Reconciliation (Choice D) is not applicable as the client has not made a realistic adjustment to the illness but rather is in denial of its severity.

5. Which type of toy would be most suitable for enhancing the development of a toddler-age client?

• A. Clay
• B. Rattle
• C. Video games
• D. Musical mobile

Correct answer: A

Rationale: The most suitable toy to recommend for enhancing the development of a toddler-age child is clay. Clay promotes creativity and fine motor skills in toddlers. A rattle is typically recommended for infants as it aids in sensory development. Video games, which are often battery-operated, are not suitable for toddlers due to potential negative effects on development. A musical mobile is more appropriate for infants as it can aid in soothing and sensory stimulation.

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