Nursing Elites

1. A 20-year-old female client with noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?

• A. Accept and document the client's wish to refrain from bathing.
• B. Offer to give the client a bed bath, avoiding the perineal area.
• C. Obtain written brochures about menstruation to give to the client.
• D. Teach the importance of personal hygiene during menstruation to the client.

Correct answer: D

Rationale: The correct answer is to teach the importance of personal hygiene during menstruation to the client. While respecting the client's beliefs, it is essential to provide education on maintaining hygiene during menstruation. This empowers the client with knowledge to make informed decisions. Options A and B can be considered after providing education. Option C, obtaining brochures, is not the priority as direct communication and teaching would be more effective in addressing the client's concerns.

2. Which intervention would the nurse implement to develop a caring relationship with the client's family?

• A. Deciding health care options for the client
• B. Identifying the client's family members and their roles
• C. Declining to inform the client's family after performing a procedure
• D. Refraining from discussing the client's health with the family

Correct answer: B

Rationale: To establish a caring relationship with the client's family, the nurse should start by identifying the family members and understanding their roles in the client's life. This step is crucial in determining how they can contribute to the client's healthcare and support. Deciding healthcare options for the client (Choice A) is not the nurse's role; it should be a collaborative decision with the client and family. Declining to inform the client's family after a procedure (Choice C) goes against transparency and collaboration in care. Refraining from discussing the client's health with the family (Choice D) can hinder effective communication and support, which are essential in developing a caring relationship with the family.

3. After undergoing dilation and curettage following an early miscarriage, a client is crying. Which response would the nurse give?

• A. ''This must be a very difficult experience for you to deal with.''
• B. 'You'll have other children to take the place of the child you lost.''
• C. 'Of course you're sad now, but at least you know you can get pregnant.''
• D. 'I know how you feel, but when a woman miscarries, it's usually for the best.''

Correct answer: A

Rationale: The correct response acknowledges the client's grief without judgment and provides validation. Choice B is inappropriate as it suggests replacing the lost child with other children, which is insensitive and dismissive of the client's current loss. Choice C minimizes the client's feelings by focusing on the ability to get pregnant rather than addressing the emotional impact of the miscarriage. Choice D is dismissive and patronizing, suggesting that the miscarriage was for the best, which can be hurtful and diminish the client's grief.

4. A client is undergoing treatment for alcoholism. Twelve hours after their last drink, they develop tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: In alcohol withdrawal, stage 3 typically begins about 12-48 hours after the last drink. It includes symptoms from stages 1 and 2 like tremors, tachycardia, mild hallucinations, hyperactivity, and confusion. By stage 3, severe hallucinations and seizures can occur. Choice A, stage 1, is too early for the described symptoms. Stage 2, as described, is also too early as it typically occurs within 6-12 hours. Stage 4 is not a recognized stage in alcohol withdrawal protocols.

5. Which action should the nurse implement when providing wound care instructions to a client who does not speak English?

• A. Ask an interpreter to provide wound care instructions.
• B. Speak directly to the client, with an interpreter translating.
• C. Request the accompanying family member to translate.
• D. Instruct a bilingual employee to read the instructions.

Correct answer: B

Rationale: When providing wound care instructions to a client who does not speak English, the nurse should speak directly to the client with the assistance of an interpreter for accurate translation. The interpreter is trained to provide objective translations in the client's primary language, ensuring the client understands the instructions and can ask questions. Using family members for translation is discouraged as they may alter instructions or feel uncomfortable discussing certain topics. Instructing a bilingual employee to read the instructions is not ideal as they may lack the necessary training in accurate interpretation, which could lead to misunderstandings in crucial wound care instructions.

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