Nursing Elites

1. Which of the following interventions is essential when working with a client who has antisocial personality disorder?

• A. Monitor intake and output
• B. Set strict limits on behavior
• C. Provide diversion for the client
• D. Limit visits from family or friends

Correct answer: B

Rationale: When working with a client diagnosed with antisocial personality disorder, it is crucial to set strict limits on their behavior. This disorder is characterized by manipulative behavior, impulsivity, and deceitfulness. By setting strict limits, the nurse can establish boundaries to prevent the client from manipulating others or engaging in disruptive behaviors. Monitoring intake and output (Choice A) is not directly related to managing antisocial personality disorder. Providing diversion (Choice C) or limiting visits from family or friends (Choice D) may not address the core issues associated with this disorder, such as manipulation and boundary violations.

2. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce embolism occurrence.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints, maintaining joint mobility, and preventing stiffness in immobile clients. This intervention helps preserve muscle strength and joint function. Options B, C, and D are incorrect because: Option B suggesting decreasing fluid intake to prevent diarrhea is not relevant to preventing complications of immobility and could lead to dehydration; Option C, massaging the client's legs to reduce embolism occurrence, is not a recommended practice as massage can dislodge blood clots and increase the risk of embolism; Option D, turning the client from side to back every shift, is not sufficient as it does not address the need for maintaining joint mobility and preventing contractures in immobile clients.

3. Which client is most likely to be at risk for spiritual distress?

• A. Roman Catholic woman considering an abortion
• B. Jewish man considering hospice care for his wife
• C. Seventh-Day Adventist who needs a blood transfusion
• D. Muslim man who needs a total knee replacement

Correct answer: A

Rationale: The correct answer is the Roman Catholic woman considering an abortion. In the Roman Catholic faith, abortion is strictly prohibited, so making a decision regarding abortion can bring about spiritual distress. The Jewish faith does not have restrictions on hospice care. It is Jehovah's Witnesses, not Seventh-Day Adventists, who do not accept blood transfusions due to religious beliefs. Additionally, there are no religious prohibitions against joint replacement in the Muslim faith.

4. After giving birth to her third child, a client tearfully says to the nurse, 'How much more can I give of myself?' Which principle would the nurse consider in the care of any new mother?

• A. It is easier to adjust to the first child than to later ones.
• B. Feeling anger and resentment toward a child is pathological.
• C. Some parents experience feelings of being overwhelmed by multiple children.
• D. Parents usually have inborn feelings of love and acceptance of their children.

Correct answer: C

Rationale: A parent's feeling of being overwhelmed by multiple children is a normal response. It is vital to help parents realize this as a means of easing feelings of guilt and shame. The first child causes the greatest amount of adjustment in one's life. It is common for parents to feel anger and resentment toward their children at times due to the challenges of parenting. Stating that parents usually have inborn feelings of love and acceptance of their children is a false generalization and may not hold true for everyone. Therefore, the most appropriate principle for the nurse to consider in this situation is that some parents may experience feelings of being overwhelmed by multiple children.

5. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Change the IV solution bag.

Correct answer: B

Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.

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