Nursing Elites

1. A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:

• A. "The amount of alcohol that is safe during pregnancy is unknown."?
• B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
• C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
• D. "You can have a drink to help you relax and get to sleep at night."?

Correct answer: A

Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? This response is appropriate because there is no known safe amount of alcohol consumption during pregnancy. Consuming any amount of alcohol during pregnancy can pose risks to the developing fetus, leading to conditions like fetal alcohol syndrome, which is a combination of mental and physical abnormalities in infants. Choices B, C, and D are incorrect. Choice B suggests that consuming one or two drinks a day is safe during pregnancy, which is not supported by current medical guidelines. Choice C incorrectly states that only drinking three or more drinks on any given occasion is harmful, when in reality, any amount of alcohol can be harmful to the fetus. Choice D is inappropriate as it suggests that having a drink to relax and sleep is acceptable during pregnancy, which is not the case.

2. A client reports that he is 'talking to the voices.' The nurse observes this behavior. The nurse's next action should be:

• A. touching the client to help him return to reality
• B. leaving the client alone until reality returns
• C. asking the client to describe what is happening
• D. telling the client there are no voices

Correct answer: A

Rationale: When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently. Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.

3. An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?

• A. knowledge that elder abuse is rare
• B. personal belief that abuse is deserved
• C. lack of developmentally appropriate screening tools
• D. fear of reprisal or further violence if the incident is reported

Correct answer: D

Rationale: One of the significant barriers for elderly clients to admit being victims of abuse is the fear of reprisal or further violence if the incident is reported. Elderly individuals may be afraid of the consequences of reporting abuse, such as retaliation or increased violence from the abuser. This fear can prevent them from disclosing their victimization. Choices A and C are incorrect as knowledge of the rarity of elder abuse and the availability of appropriate screening tools do not directly impact the client's willingness to admit abuse. Choice B, personal belief that abuse is deserved, may be a factor for some individuals but is not as common or impactful as the fear of reprisal or further violence.

4. A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.

• A. "You feel inadequate because you have never learned to balance a checkbook."?
• B. "You should have insisted your husband teach you about the finances."?
• C. "You are strong and will learn how to manage your finances after a while."?
• D. "Why don't you take a class in basic finance from the local college?"?

Correct answer: C

Rationale: The nurse can raise the client's self-esteem by acknowledging the client's feelings and providing positive reinforcement. Choice C shows empathy and support by recognizing the client's strength and potential to learn. This response encourages the client to believe in her abilities and instills confidence. Choices A and B may come across as judgmental or critical, which can further lower the client's self-esteem. Choice D, while offering a solution, does not address the client's emotional needs or provide direct reassurance about her capabilities.

5. After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:

• A. verbalizing the implied.
• B. seeking consensual validation.
• C. encouraging evaluation.
• D. suggesting collaboration.

Correct answer: B

Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.

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