Nursing Elites

1. What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?

• A. Ask where the client obtained the alcohol.
• B. Locate the alcoholic substance.
• C. Convey empathy and support to the client.
• D. Document the client's drinking behavior.

Correct answer: B

Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.

2. During a scheduled health maintenance visit, which common source of stress for a 6-year-old client would the nurse include in the teaching session?

• A. Wanting to be first
• B. Demanding privacy
• C. Having a desire to be like an idol
• D. Being more selective with playmates

Correct answer: A

Rationale: A common source of stress for a 6-year-old school-age client is competition, such as wanting to be first or the best (winning). This aspect can create stress for a 6-year-old as they navigate social interactions and activities. Therefore, the nurse would address this issue during the teaching session at the health maintenance visit. Demanding privacy, having a desire to be like an idol, and being more selective with playmates are characteristics more commonly associated with 7-year-old clients, not typically seen in the stressors of a 6-year-old. Understanding age-appropriate stressors is crucial for providing tailored education and support in pediatric care.

3. Identify the type of 'trigger' with the correct 'trigger' that can possibly lead to disturbed behavior.

• A. Emotional: room coldness
• B. Environmental: boredom
• C. Physical: pain
• D. Communication: silence

Correct answer: C

Rationale: Physical pain is a common trigger that can lead to disturbed behavior in individuals, especially when they are unable to communicate their pain effectively. Choices A, B, and D are incorrect. Room coldness falls under environmental triggers, boredom is associated with emotional triggers, and silence is a communication aspect rather than a direct trigger for disturbed behavior.

4. While explaining an illness to a 10-year-old, what should the nurse keep in mind about cognitive development at this age?

• A. They are able to make simple associations of ideas.
• B. They are able to think logically in organizing facts.
• C. Interpretation of events originates from their own perspective.
• D. Conclusions are based on previous experiences.

Correct answer: B

Rationale: The correct answer is that 10-year-olds are able to think logically in organizing facts. At this age, children are in the concrete operational stage according to Piaget's theory of cognitive development. In this stage, they can understand and organize information logically and can manipulate objects mentally. Choice A is incorrect because simple associations of ideas are more characteristic of earlier developmental stages. Choice C is incorrect as it refers to egocentrism, which is more typical of the preoperational stage. Choice D is incorrect as basing conclusions on previous experiences is a broader concept that applies across different ages and stages of development, rather than being specific to 10-year-olds in the concrete operational stage.

5. During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important?

• A. Understanding what will be discussed
• B. Knowing that the nurse is trying to be helpful
• C. Knowing what to expect from the relationship
• D. Preparing for termination of the relationship

Correct answer: C

Rationale: During the initial stages of a therapeutic relationship, having a clear understanding of participants' roles is crucial as it helps in defining the structure and boundaries of the relationship. This clarity assists in setting expectations and establishing a framework for interaction, allowing the client to focus on the therapeutic process rather than on uncertainties regarding their role or the nurse's role. Option A, understanding what will be discussed, is important but not directly related to defining roles. Option B, knowing that the nurse is trying to be helpful, is about the intent of the nurse rather than the roles of the participants. Option D, preparing for termination of the relationship, is premature in the beginning phase and not directly related to understanding roles.

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