Nursing Elites

1. A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?

• A. Pulse characteristics
• B. Open airway
• C. Entrance and exit wounds
• D. Cervical spine injury

Correct answer: A

Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.

2. A client has just died, and their son states, 'She was the most wonderful mother. There was no one who was a better mother than she was. She was perfect.' Which stage of grief is this son experiencing?

• A. Denial
• B. Anger
• C. Idealization
• D. Shock

Correct answer: C

Rationale: The son is experiencing the idealization stage of grief. During this stage, individuals tend to idealize the deceased person and remember them in a highly positive light, overlooking any negative aspects. This idealization serves as a coping mechanism to deal with the loss. Choice A, Denial, is incorrect as denial involves refusing to accept the reality of the loss. Choice B, Anger, is incorrect as it involves feelings of resentment and frustration. Choice D, Shock, is incorrect as shock is the initial reaction to the loss and is different from idealizing the deceased individual.

3. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?

• A. Maintain standard precautions.
• B. Initiate contact isolation measures.
• C. Insert an indwelling urinary catheter.
• D. Instruct the client in the use of adult diapers.

Correct answer: A

Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.

4. Which risk factor for suicide is considered the most lethal?

• A. History of alcohol and drug abuse
• B. Previous high-lethality suicide attempts
• C. Recent withdrawal from friends
• D. Disturbance of family dynamics

Correct answer: B

Rationale: The correct answer is 'Previous high-lethality suicide attempts.' This is the most lethal risk factor as it indicates that the individual has previously attempted suicide in a manner that could lead to death. This history increases the likelihood of future attempts. While substance abuse, like alcohol and drug use, is a significant risk factor for suicide, it is not considered the most lethal. Withdrawal from friends or social isolation can contribute to suicide risk but is not as directly deadly as high-lethality attempts. Disturbance of family dynamics can also be a stressor but does not represent the immediate lethality associated with a history of high-lethality suicide attempts.

5. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?

• A. Determine how well the client can change the dressing.
• B. Ask the client to demonstrate the procedure.
• C. Seek a family member's opinion on the client's dressing change ability.
• D. Observe the client change the dressing unassisted.

Correct answer: D

Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.

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