Nursing Elites

1. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?

• A. "I can always trust my family."?
• B. "It seems like I always have bad luck."?
• C. "You never know who will turn against you."?
• D. "I hear evil voices that tell me to do bad things."?

Correct answer: D

Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.

2. For a healthcare worker under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?

• A. At least a 15-second scrub with plain soap and water
• B. At least a 23-minute scrub with an antimicrobial soap
• C. Use of an alcohol-based antiseptic hand-rub
• D. Wearing a mask when scrubbing

Correct answer: C

Rationale: Effective hand hygiene between patients for a healthcare worker with unsoiled hands involves using an alcohol-based antiseptic hand rub. This method is sufficient for cleaning hands that are not visibly soiled. The use of an antimicrobial soap or a prolonged scrubbing time is unnecessary and not recommended in this scenario. Wearing a mask is not required for routine hand hygiene and does not contribute to effective hand cleaning.

3. What message is a patient sending when displaying the following body language: Slumped shoulders, grimace, and stiff joints?

• A. Anger
• B. Aloofness
• C. Empathy
• D. Depression

Correct answer: A

Rationale: Body language is a powerful form of non-verbal communication that can convey various emotions. In this scenario, the patient's slumped shoulders, grimace, and stiff joints suggest a negative emotional state. Anger is the correct answer because grimacing and tense posture are commonly associated with anger. Choice B, 'Aloofness,' is incorrect as aloofness is more related to disinterest or detachment, which is not indicated by the described body language. Choice C, 'Empathy,' is incorrect as the body language described does not align with expressing understanding or compassion towards others. Choice D, 'Depression,' is incorrect as while depression can also manifest through body language, the specific cues given in the scenario lean more towards anger than depression.

4. To collect timely, specific information, the nurse is most likely to ask which of the following questions?

• A. Would you describe what you are feeling?
• B. How are you today?
• C. What would you like to talk about?
• D. Where does it hurt?

Correct answer: A

Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'

5. A patient is in the office for a cyst removal and is very anxious about the procedure. Which of the following descriptions of his respirations would be expected?

• A. Bradypnea
• B. Orthopnea
• C. Tachypnea
• D. Dyspnea

Correct answer: C

Rationale: Tachypnea is defined as a rapid, quick, and shallow respiration rate. When a patient is anxious, they may hyperventilate, leading to tachypnea. Bradypnea (Choice A) is slow breathing, which is not expected in an anxious patient. Orthopnea (Choice B) is difficulty breathing while lying down and is not directly related to anxiety. Dyspnea (Choice D) is shortness of breath, which may not be the primary respiratory pattern seen in an anxious patient undergoing a procedure. Therefore, the correct choice is tachypnea as it aligns with the expected respiratory response to anxiety.

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