Nursing Elites

1. Which statement by an 8-year-old girl, who was just admitted to the hospital, needs to be explored?

• A. ''Wow! This hospital has bright colors.''
• B. ''Is my mother allowed to visit me tonight?'
• C. ''Those boys are so cute. I hope their room is next to mine!'
• D. ''I'm scared about being here. Can you stay with me awhile?'

Correct answer: C

Rationale: The correct answer is C. An 8-year-old child showing a strong attraction to boys at this age may raise concerns about precocious sexual behavior or exposure to inappropriate sexual content, potentially signaling the need to investigate for possible sexual abuse. It is important to explore this statement further. Choice A, expressing admiration for bright colors, is a common behavior for children of this age and does not raise immediate concerns. Choice B, inquiring about the mother's visit, is a typical concern for a hospitalized child seeking comfort and support. Choice D, expressing fear and seeking reassurance from the nurse, is also a normal reaction for an 8-year-old in a new and possibly intimidating environment. However, the statement in Choice C stands out as it deviates from age-appropriate behavior and warrants further exploration to ensure the child's safety and well-being.

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: B

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. A client asks the nurse, 'Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?' Which is the nurse's most appropriate response?

• A. Do not tell your partner unless asked.
• B. This is a decision you alone can make.
• C. You are having difficulty deciding what to say.
• D. Tell your partner that you don't know how you became sick.

Correct answer: C

Rationale: The most appropriate response for the nurse in this situation is to acknowledge the client's struggle in deciding what to communicate to their partner. By stating 'You are having difficulty deciding what to say,' the nurse validates the client's feelings and encourages further discussion. Option A is incorrect as it suggests withholding information unless asked, which may not align with ethical principles of honesty and transparency in relationships. Option B, while acknowledging the client's autonomy, does not provide direct support or guidance. Option D is inappropriate as it involves dishonesty by suggesting telling the partner an untruthful reason for the illness.

4. Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?

• A. Touch
• B. Silence
• C. Focusing
• D. Summarizing

Correct answer: C

Rationale: Focusing is the appropriate therapeutic technique to use when an anxious client exhibits pressured and rambling speech. By focusing on one specific aspect, the intended meaning is easier to understand and helps the client stay on track. Touch is not recommended in this scenario as it can invade the client's personal space and potentially increase anxiety. Silence may allow the client to continue rambling without addressing the underlying concerns. Summarizing requires the identification and exploration of the client's concerns, which may be challenging when the speech is pressured and disorganized.

5. Which is the most appropriate nursing intervention when providing care for parents who have experienced a stillbirth?

• A. Giving a detailed explanation of possible causes of the stillbirth
• B. Providing the parents the opportunity to say goodbye to their newborn
• C. Explaining that an autopsy is not recommended in the setting of a stillbirth
• D. Arranging follow-up care and providing information to the parents before they leave the hospital

Correct answer: B

Rationale: The most appropriate nursing intervention when caring for parents who have experienced a stillbirth is to provide them with the opportunity to say goodbye to their newborn. This helps in the grieving process and allows the parents closure. Giving a detailed explanation of possible causes of the stillbirth may overwhelm the parents and is not the immediate priority. While an autopsy can be performed in the case of a stillbirth, the decision should be discussed with the parents and their wishes respected. Arranging follow-up care and providing information before the parents leave the hospital is crucial in ensuring they have the necessary support and resources to cope with the loss effectively.

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