Nursing Elites

1. Which of the following outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

• A. The client will verbalize community resources from which to seek shelter after discharge.
• B. The client will write a plan to keep herself and her children safe.
• C. The client will contact an attorney for help with pressing charges.
• D. The client will be safe and receive treatment for injuries.

Correct answer: D

Rationale: During the crisis stage of caring for a victim of domestic violence, the immediate priority is ensuring the client's safety and providing treatment for any injuries sustained. This focuses on addressing the urgent physical and emotional needs of the victim. While options like verbalizing community resources or creating safety plans are important for long-term support, they are not the primary concerns during the crisis phase. Contacting an attorney for legal assistance, though vital in the future, is not the immediate priority during the crisis stage when the client's safety and health are at the forefront.

2. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

• A. Have you had a recent heart attack?
• B. Do you become short of breath during your normal daily activities?
• C. How many pillows do you use at night to sleep comfortably?
• D. Do you smoke?

Correct answer: B

Rationale: The correct answer is asking about shortness of breath during normal daily activities because these symptoms suggest right-sided heart failure, leading to increased pressure in the systemic venous system. This pressure causes fluid to shift into the interstitial spaces, resulting in edema. In an ambulatory patient, lower extremities are typically affected first due to gravity. By asking about shortness of breath, the nurse can gather information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. The other choices are less relevant in this context and do not directly address the client's presenting symptoms.

3. Which nursing action promotes psychosocial development for a newborn?

• A. Washing hands before holding the newborn
• B. Measuring the newborn using an approved length board
• C. Weighing the newborn on the same scale during hospitalization
• D. Placing the newborn in the mother's arms during the first hour of life

Correct answer: D

Rationale: Placing the newborn in the mother's arms during the first hour of life is a crucial nursing action that promotes psychosocial development by fostering bonding between the newborn and the mother. This skin-to-skin contact enhances emotional attachment, facilitates breastfeeding initiation, and provides a sense of security for the newborn. It helps in regulating the newborn's temperature, heart rate, and breathing, promoting overall well-being. Washing hands before holding the newborn is essential for infection prevention and control to maintain the newborn's health and safety. Measuring the newborn using an approved length board and weighing the newborn on the same scale during hospitalization are assessments aimed at monitoring the newborn's physical growth and development, rather than directly promoting psychosocial well-being.

4. Which of the following is a nursing intervention for a client who is experiencing an acute panic attack?

• A. Encourage the client to sit down in a quiet environment
• B. Allow the client to direct the situation
• C. Try to focus the client on one aspect of care, such as regulating breathing patterns
• D. Speak in a commanding tone of voice to get the client's attention

Correct answer: C

Rationale: When assisting a client with an acute panic attack, the primary goal is to help reduce their anxiety levels. Encouraging the client to focus on one controllable aspect, like regulating breathing patterns, can aid in calming them down. This intervention helps the client to regain control over their breathing, which can alleviate some of the symptoms associated with panic attacks. Options A and B are incorrect because allowing the client to direct the situation or sit down in a quiet environment may not be beneficial during an acute panic attack. Option D is inappropriate as speaking in a commanding tone can further escalate the client's anxiety rather than helping to calm them down.

5. Which communication technique is a part of therapeutic communication?

• A. Asking for explanations
• B. Showing sympathy to the client
• C. Asking personal questions of the client
• D. Providing relevant information to the client

Correct answer: D

Rationale: The correct answer is providing relevant information to the client. In therapeutic communication, it is essential to provide clients with all pertinent information to help them understand their health status and what to expect. This empowers clients and promotes trust in the nurse-client relationship. Asking for explanations, showing sympathy, and asking personal questions are examples of nontherapeutic communication techniques. Asking personal questions can intrude on the client's privacy and may not be relevant to their care. Showing sympathy, while well-intentioned, may come across as pity rather than true empathy. Asking for explanations can sometimes put clients on the defensive rather than fostering a collaborative dialogue.

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