Nursing Elites

1. While receiving a preoperative enema, a client starts to cry and says, 'I'm sorry you have to do this messy thing for me.' Which is the nurse's best response?

• A. I don't mind it.'
• B. 'You seem upset.'
• C. 'This is part of my job.'
• D. 'Nurses get used to this.'

Correct answer: B

Rationale: The nurse's best response in this situation is to acknowledge the client's emotional state, as it shows empathy and encourages further expression of feelings. Choice A, 'I don't mind it,' dismisses the client's emotions and does not address the underlying issue. Choice C, 'This is part of my job,' focuses on the task rather than the client's emotional needs. Choice D, 'Nurses get used to this,' minimizes the client's feelings and lacks empathy. By selecting choice B, 'You seem upset,' the nurse acknowledges the client's distress and opens the door for further communication and support.

2. When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?

• A. Check the bath water temperature.
• B. Shut the bathroom door.
• C. Ensure that the client has voided.
• D. Provide extra towels.

Correct answer: A

Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.

3. The client is in the maintenance stage based on the transtheoretical model of health behavior change. Which stage is the client in?

• A. Action
• B. Preparation
• C. Maintenance
• D. Contemplation

Correct answer: C

Rationale: The client is in the maintenance stage of human behavior change. During this stage, the client has successfully incorporated the changes into their lifestyle. The maintenance stage typically begins 6 months after the action stage and continues indefinitely. The action stage lasts for 6 months from when the client initially incorporates the changes. In the preparation stage, the client starts realizing that the benefits of change outweigh the disadvantages and starts making small changes to prepare for major changes in the following month. The contemplation stage involves the client considering whether to make changes in the next 6 months. Therefore, in this scenario, the client's consistent adherence to the diet and exercise program for 8 months places them in the maintenance stage of behavior change.

4. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

• A. Assist the client to walk to the bathroom and do not leave the client alone.
• B. Request that the UAP assist the client onto a bedpan.
• C. Ask if the client needs to have a bowel movement or void.
• D. Assess the client's bladder to determine if the client needs to urinate.

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. Therefore, the nurse should assist the client to the bathroom to ensure safety. Using a bedpan is not necessary if the client can safely walk to the bathroom. Asking about bowel movements or voiding, as in option C, is irrelevant to the immediate safety concern of assisting the client to the bathroom. Assessing the client's bladder, as in option D, is unnecessary in this situation as there is no indication that the client cannot communicate his or her needs effectively. The priority here is to prevent falls and ensure the client's safety while assisting to the bathroom.

5. According to psychodynamic theory, what purpose do delusions serve?

• A. Delusions are a defense against anxiety caused by real or imagined threats.
• B. Magical thinking is a delusion that ensures desirable outcomes.
• C. Delusions are a method of dealing with and interpreting external stimuli.
• D. Subconsciously, delusions are a way to safely express anger and hostility.

Correct answer: A

Rationale: According to psychodynamic theory, delusions serve as a defense mechanism against anxiety triggered by real or perceived threats. Delusions are the individual's unconscious way of protecting themselves from overwhelming feelings of anxiety. Magical thinking, on the other hand, involves believing that one's thoughts can influence external events. This is not the same as delusions. Delusions are not a way of interpreting external stimuli but rather a defense mechanism. Expressing anger and hostility is typically associated with defense mechanisms like displacement or projection, not delusions.

Similar Questions