Nursing Elites

1. Which of the following is a symptom associated with sensory overload?

• A. Disorientation
• B. Drowsiness
• C. Emotional lability
• D. Depression

Correct answer: A

Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.

2. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next?

• A. Witness the client's signature on the permit.
• B. Answer the client's questions about the surgery.
• C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
• D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to inform the surgeon that the operative permit is not signed and that the client has questions about the surgery. It is the responsibility of the surgeon to explain the procedure to the client and obtain the client's signature on the permit. While the nurse can witness the client's signature on the permit, the procedure must first be explained by the healthcare provider or surgeon, including addressing the client's questions. Therefore, informing the surgeon is the priority to ensure proper communication and consent before the surgery. Answering the client's questions about the surgery (Choice B) may not provide accurate information and could lead to misunderstanding. Reassuring the client (Choice D) is important, but obtaining proper consent and addressing concerns should come first. Witnessing the client's signature (Choice A) is not sufficient if the client has unanswered questions and the permit is not signed.

3. Which nursing intervention helps foster the development of a trusting parent-child relationship?

• A. Placing the infant in a crib with a mobile or soft toy
• B. Discouraging eye contact when the infant is irritable
• C. Putting objects several inches in front of the infant for viewing
• D. Encouraging face-to-face contact between the parents and infant

Correct answer: D

Rationale: Encouraging face-to-face contact between parents and infants is crucial in fostering a trusting parent-child relationship. Eye-to-eye contact promotes interaction and bonding, helping the infant develop trust in their caregivers. Placing the infant in a crib with a mobile or soft toy may provide stimulation but does not directly contribute to the emotional bonding necessary for trust. Discouraging eye contact when the infant is irritable can hinder communication and connection. Putting objects in front of the infant for viewing is beneficial for visual stimulation but does not actively promote the emotional attachment and trust that face-to-face contact does.

4. Which of the following is an example of non-reversible dementia?

• A. Pick's disease
• B. Syphilis
• C. Encephalopathy
• D. Hyperthyroidism

Correct answer: A

Rationale: Non-reversible dementia refers to a condition where individuals experience permanent and often progressive cognitive decline. Pick's disease is a type of non-reversible dementia characterized by changes in personality, behavior, and language difficulties. Syphilis (Choice B) is a reversible cause of dementia that can be treated with antibiotics. Encephalopathy (Choice C) is a broad term for brain dysfunction that can be reversible or irreversible depending on the cause. Hyperthyroidism (Choice D) can lead to cognitive impairment but is reversible with appropriate treatment. Therefore, Pick's disease is the correct example of non-reversible dementia among the options provided.

5. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?

• A. "I don't remember anything about what happened to me."?
• B. "I'd rather not talk about it right now."?
• C. "It's the other entire guy's fault! He was going too fast."?
• D. "My mother is heartbroken about this."?

Correct answer: A

Rationale: The correct answer is, '"I don't remember anything about what happened to me."?' Suppression involves willfully putting an unacceptable thought or feeling out of one's mind. In this case, the client is purposely choosing not to remember details of the traumatic event to avoid dealing with the associated emotions. Choice B, '"I'd rather not talk about it right now,"?' suggests avoidance or deflection rather than active suppression. Choice C, '"It's the other entire guy's fault! He was going too fast,"?' indicates blaming someone else for the situation, which is a form of defense mechanism known as externalization. Choice D, '"My mother is heartbroken about this,"?' expresses empathy towards the mother's emotions and does not demonstrate suppression of personal feelings.

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