Nursing Elites

1. Which behavior by the client exhibits denial after a recent diagnosis?

• A. Attempts to minimize the illness
• B. Lacks an emotional response to the illness
• C. Refuses to discuss the condition with the client's spouse
• D. Expresses displeasure with the prescribed activity program

Correct answer: A

Rationale: The correct answer is 'Attempts to minimize the illness.' This behavior is a classic sign of denial, where the individual tries to downplay the seriousness of the illness to cope with it. By minimizing the illness, the client avoids facing the reality of the situation, which is characteristic of denial. Lacking an emotional response to the illness suggests suppression of emotions rather than denial. Refusing to discuss the condition with the spouse may stem from other issues like relationship strain or fear of causing distress, but it doesn't directly indicate denial. Expressing displeasure with the prescribed activity program typically reflects displaced anger, not denial of the illness.

2. During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?

• A. Assign an unlicensed assistive person to transport the client via a wheelchair.
• B. Remind the client to walk carefully down the stairs until reaching a lower floor.
• C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
• D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Correct answer: B

Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.

3. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?

• A. Establish trust
• B. Increase feelings of self-worth
• C. Solidify sense of identity
• D. Improve ability to socialize

Correct answer: A

Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.

4. Which assessment data would be most important to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values?

• A. Dietary practices
• B. Concept of space
• C. Immigration status
• D. Role within the family

Correct answer: D

Rationale: The most important assessment data to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values is their role within the family. In traditional Asian cultures, the family holds significant importance and plays a central role in influencing an individual's well-being. Understanding the client's role within the family can provide crucial insights into their support system, stressors, and coping mechanisms. Dietary practices, concept of space, and immigration status, while potentially relevant, are not as vital in this context compared to understanding the dynamics and influence of the family structure on the individual's mental health.

5. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

• A. Make the client comfortable and allow the client to sleep.
• B. Assess the client's neurologic status.
• C. Notify the surgeon about the comment.
• D. Ask the client's family to co-sign the operative permit.

Correct answer: B

Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.

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