Nursing Elites

1. Your patient has been confused for years. Your patient can be best described as having a chronic ___________ disorder.

• A. physical
• B. psychotic
• C. thinking
• D. palliative

Correct answer: C

Rationale: Patients who experience long-term confusion often have a chronic thinking, or cognitive, disorder. Alzheimer's disease is a prime example of a disorder that results in prolonged confusion and memory loss. Choice A, 'physical', is incorrect as the issue described is related to cognitive functioning, not physical health. Choice B, 'psychotic', refers to a severe mental disorder characterized by a loss of contact with reality, which is not the primary issue presented in the scenario. Choice D, 'palliative', is not relevant as it pertains to specialized medical care for individuals with serious illnesses, focusing on providing relief from symptoms and stress rather than managing chronic confusion.

2. Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?

• A. Asking to speak to someone
• B. Asking to be alone
• C. Listening to music
• D. All of the above

Correct answer: D

Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.

3. A client is having difficulty applying for a job due to panic and anxiety. A nurse is helping by pretending to be the job supervisor while the client practices answering questions during an imaginary interview. This technique is an example of:

• A. Reinforcement
• B. Presenting reality
• C. Role playing
• D. Summarizing

Correct answer: C

Rationale: Role-playing is the correct answer. It involves practicing appropriate behaviors during imaginary scenarios that simulate real-life situations. In this scenario, the nurse is helping the client prepare for a job interview by acting as the job supervisor. Role-playing allows the client to practice and develop strategies to cope with anxiety and panic during the actual interview. Reinforcement (Choice A) involves providing consequences to strengthen a behavior. Presenting reality (Choice B) involves helping the client differentiate between real and unreal experiences. Summarizing (Choice D) involves condensing information. In this context, role-playing is the most appropriate technique to address the client's anxiety and panic related to job interviews.

4. 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.

5. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?

• A. Clamp the catheter and recheck it in 60 minutes.
• B. Pull the catheter back 3 inches and redirect upward.
• C. Leave the catheter in place and reattempt with another catheter.
• D. Notify the healthcare provider of a possible obstruction.

Correct answer: C

Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option D) as the catheter could be inserted easily.

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