Nursing Elites

1. Which behavioral characteristic describes the domestic abuser?

• A. Alcoholic
• B. Overconfident
• C. High tolerance for frustrations
• D. Low self-esteem

Correct answer: D

Rationale: The correct answer is 'Low self-esteem.' Domestic abusers often exhibit behaviors stemming from their own experiences of abuse, leading to a cycle of violence. They commonly have low self-esteem, which drives their need to exert control and power over their partners. Choice A, 'Alcoholic,' is not a defining behavioral characteristic of domestic abusers. Choice B, 'Overconfident,' is not typically associated with abusers who often exhibit insecurity and control issues. Choice C, 'High tolerance for frustrations,' is not a primary characteristic of domestic abusers; rather, they often have a low tolerance for situations that challenge their need for control.

2. When a client who has had a mastectomy sees her incision for the first time, she exclaims, 'I look horrible! Will it ever look better?' Which response would the nurse provide?

• A. 'You seem shocked by the way you look now.'
• B. 'Now that the tumor is gone, the area will heal quickly.'
• C. After it heals, others won't even know you had surgery.'
• D. 'You will feel better about it when the swelling subsides.'

Correct answer: A

Rationale: The correct response, 'You seem shocked by the way you look now,' acknowledges the client's feelings and provides an opportunity for the client to express emotions freely. This reflection of feelings may help promote eventual acceptance of body image changes. Choices B, C, and D provide false reassurance and negate the client's feelings. Saying that the area will heal quickly now that the tumor is gone dismisses the client's concerns. Similarly, stating that others won't know about the surgery or that the client will feel better once the swelling subsides does not address the client's current emotional state and may undermine trust in the nurse-client relationship.

3. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?

• A. Ask the client to remain quiet so the procedure can be performed safely.
• B. Concentrate on completing the insertion as efficiently as possible.
• C. Calmly reassure the client that the discomfort will be temporary.
• D. Tell the client a joke as a means of distraction from the procedure.

Correct answer: C

Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.

4. 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.

5. Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?

• A. 'Getting angry is not appropriate; let's address this calmly.''
• B. ''Yelling is not acceptable and won't help us resolve this issue.''
• C. 'You must eat the first tray of food, and then I'll get another tray for you.''
• D. 'It must be frustrating to get the wrong tray. I'll order another tray for you.''

Correct answer: D

Rationale: The most appropriate response from the nurse would be, ''It must be frustrating to get the wrong tray. I'll order another tray for you.'' When interacting with clients with borderline personality disorder, it is crucial for nurses to acknowledge the client's emotions empathetically and provide constructive solutions. While expressing anger is understandable, guiding the client towards a more constructive approach is essential. Yelling is not a helpful way to address the situation and threatening seclusion is inappropriate. Additionally, instructing the client to eat the first tray before receiving another one is punitive and disregards the client's preferences and rights.

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