Nursing Elites

1. Which source of stress would the nurse anticipate in a 5-year-old client?

• A. Jealousy
• B. Stubbornness
• C. Procrastination
• D. Companionship

Correct answer: C: Procrastination

Rationale: Procrastination, which refers to delaying completing chores or activities, is a common source of stress for 5-year-old clients. At this age, children may start experiencing stress related to the pressure of tasks or expectations. Jealousy and stubbornness are more typical sources of stress for 3- and 4-year-old clients who are still developing social and emotional skills. Companionship, on the other hand, is generally seen as a positive aspect in a child's life and is not typically a source of stress but rather a source of support and comfort.

2. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention?

• A. The cuff wraps around the girth of the leg.
• B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
• C. The client is placed in a prone position.
• D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

Correct answer: The UAP auscultates the popliteal pulse with the cuff on the lower leg.

Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse should be auscultated when the blood pressure cuff is applied around the thigh. The nurse should intervene when the UAP is auscultating the popliteal pulse with the cuff on the lower leg because this is incorrect placement. Option A, wrapping the cuff around the girth of the leg, ensures an accurate assessment. Option C, placing the client in a prone position, provides the best access to the artery. The systolic pressure in the popliteal artery is typically 10 to 40 mm Hg higher than in the brachial artery, so a systolic reading 20 mm Hg higher than the blood pressure in the client's arm is within the expected range and does not require intervention.

3. The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to their daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine they are currently following.

Correct answer: Ask the client to describe the routine they are currently following.

Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.

4. The primary health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. Which nursing action will be most helpful in easing the mother’s stress when she sees her child for the first time?

• A. Bringing the infant as requested before she changes her mind
• B. Describing how the infant looks before bringing the infant to her
• C. Staying with her after bringing the infant to help her verbalize her feelings
• D. Showing the mother pictures of the birth defects, then bringing the infant to her

Correct answer: Staying with her after bringing the infant to help her verbalize her feelings

Rationale: Allowing the mother time to verbalize her feelings and providing support when she sees her newborn with birth defects for the first time is crucial. Staying with her allows for immediate emotional support, acceptance, and understanding, which can help ease her stress. Bringing the infant as requested without proper emotional support may overwhelm the mother. Describing the infant's appearance before she sees the baby might not be accurate and could add to her distress. Showing pictures of the birth defects before the mother sees her baby may not be helpful and could increase her anxiety. Engaging in discussions about treatment at this point may be premature and overwhelming for the mother.

5. A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?

• A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
• B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
• C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.
• D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

Correct answer: There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.

Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith from malpractice claims, regardless of the client outcome. In this scenario, the nurse stopped at the scene voluntarily to render aid, which is protected under the Good Samaritan Act. This law shields individuals from legal liability when providing emergency care in good faith and without expectation of compensation. The Patient's Bill of Rights does protect clients, but in this case, the nurse's actions were protected by the Good Samaritan Act. Additionally, the state Board of Nursing would not likely revoke the nurse's license unless there was evidence of actions taken in bad faith or unreasonable care. The client would not win the lawsuit as the essential elements of malpractice, including duty, breach, causation, and damages, were not met in this situation.

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