Nursing Elites

1. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?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Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust.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.

2. What would be the first step for a nurse in efficiently addressing a situation of moral dilemma?

• A. Helping the client make a moral decision
• B. Recognizing one's own moral development level
• C. Abiding by the decision of the hospital authority
• D. Having one's own opinion that differs from the health care team

Correct answer: B

Rationale: The correct first step for a nurse in efficiently addressing a moral dilemma is to recognize their own moral development level. By understanding their own moral reasoning, a nurse can effectively navigate moral challenges. Helping clients make moral decisions comes after the nurse has assessed their own moral standpoint. Abiding by hospital authority decisions may not always align with a nurse's ethical beliefs, so it's crucial for a nurse to form their own opinions and communicate concerns with the healthcare team to ensure ethical practice and decision-making.

3. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. Therefore, the nurse should assist the client to the bathroom to ensure safety. Using a bedpan is not necessary if the client can safely walk to the bathroom. Asking about bowel movements or voiding, as in option C, is irrelevant to the immediate safety concern of assisting the client to the bathroom. Assessing the client's bladder, as in option D, is unnecessary in this situation as there is no indication that the client cannot communicate his or her needs effectively. The priority here is to prevent falls and ensure the client's safety while assisting to the bathroom.

4. When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she 'can't handle' the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent?

• A. The family cannot provide the consent required in this situation as the older adult is capable of making decisions.
• B. The son cannot waive informed consent for the client since there is no evidence of mental incompetence.
• C. The court will not allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
• D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

Correct answer: D

Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so the family cannot provide consent without her involvement, making option A incorrect. There is no evidence of mental incompetence in the client, so the son cannot waive informed consent, making option B incorrect. While therapeutic privilege may have been accepted in the past, it is unlikely to be upheld by today's courts, making option C incorrect. It is crucial for health care providers to obtain informed consent from clients before proceeding with any treatment to avoid legal consequences and uphold ethical standards.

5. The mother of a 5-month-old is being educated about her baby's nutrition by the nurse. Which statement by the mother indicates the need for further teaching?

• A. ''I'm going to try feeding my baby some rice cereal.''
• B. ''When he wakes at night for a bottle, I feed him.''
• C. ''I dip his pacifier in honey so he'll take it.''
• D. ''I keep formula in the refrigerator for 24 hours.''

Correct answer: C

Rationale: The correct answer is ''I dip his pacifier in honey so he'll take it.'' This statement indicates a need for further teaching because honey should be avoided in infants due to the risk of infant botulism. Honey may contain spores of Clostridium botulinum, which can lead to serious illness in infants as they lack the necessary digestive enzymes to eliminate the spores. Feeding rice cereal, responding to night-time feedings, and storing formula in the refrigerator are appropriate practices for infant care, indicating understanding of the instructions.

Similar Questions