Nursing Elites

1. Which of the following examples indicates that the nurse is giving recognition as a form of therapeutic communication?

• A. You need to take your medicine now, Adam.
• B. Jill, your father is trying to make amends with you.
• C. The physician wants to meet with you and your husband, Amy.
• D. Linda, you brushed your hair this morning.

Correct answer: A

Rationale: Recognition is a form of therapeutic communication in which the nurse points out a positive aspect of the client's behavior. Noting that a client brushed her hair herself indicates that the nurse recognizes the client's attempts at self-care. This recognition shows the client that the nurse is paying attention and may be open to further communication. Choices A, B, and C do not demonstrate recognition. Choice A focuses on a directive statement, Choice B involves informing the client about a situation without acknowledging their actions, and Choice C informs the client about a meeting without providing recognition for any behavior.

2. Which intervention should the nurse use for a client who hallucinates, yells, and curses throughout the day?

• A. Ignore the client's behavior if the client is not harming anyone.
• B. Isolate the client until the behavior decreases or stops.
• C. Explain how the behavior affects other people on the unit.
• D. Seek to understand what the behavior means to the client.

Correct answer: D

Rationale: When a client experiences hallucinations, yells, and curses, it is essential to seek to understand the underlying meaning of their behavior. All behavior has significance, and understanding the client's perspective can guide appropriate interventions. Ignoring the behavior may exacerbate the situation and isolating the client could lead to increased anxiety and further acting out. Explaining the impact on others is not helpful in this scenario as the client is not intentionally hallucinating; yelling and cursing are responses to the hallucinations.

3. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

• A. Encourage the client to increase ambulation in the room.
• B. Offer the client a high-carbohydrate snack for energy.
• C. Force fluids to thin the client's pulmonary secretions.
• D. Determine if pain is causing the client's tachypnea.

Correct answer: D

Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate). Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload. Therefore, determining the role of pain in tachypnea is crucial for appropriate management.

4. Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?

• A. ''Tell me more about being Joan of Arc.''
• B. 'We both know that you're not Joan of Arc.''
• C. ''It seems like the world is a pretty scary place for you.''
• D. 'You're safe here, because we won't let you be burned.''

Correct answer: C

Rationale: The nurse would say, ''It seems like the world is a pretty scary place for you.'' This response allows the nurse to understand the symbolism, reflect on and acknowledge the client's feelings, and help preserve the client's integrity. The statement, ''Tell me more about being Joan of Arc,'' validates the client's delusion and does not test reality. The statement, ''We both know that you're not Joan of Arc,'' rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement, ''You're safe here, because we won't let you be burned,'' is false reassurance; the nurse is agreeing with the client's false perceptions of reality, which is nontherapeutic.

5. Which is a true statement regarding stress related disorders?

• A. Stress related disorders are only caused by stress
• B. Symptoms of stress related disorders would not exist if the client was not experiencing stress
• C. Stress related disorders are also called psycho-physiologic disorders
• D. None of the above

Correct answer: C

Rationale: The correct answer is that stress related disorders are also called psycho-physiologic disorders. These disorders have a physiologic basis for their development, but stress can exacerbate the symptoms. While stress plays a significant role in these disorders, they are not solely caused by stress. Choice A is incorrect as stress is a contributing factor rather than the sole cause. Choice B is incorrect because symptoms of stress related disorders can persist even when the individual is not actively experiencing stress. Choice D is incorrect as there is a true statement among the choices, which is that stress related disorders are also known as psycho-physiologic disorders.

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