Nursing Elites

1. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the healthcare provider as soon as possible?

• A. Daily black, sticky stool
• B. Daily dark brown stool
• C. Firm brown stool every other day
• D. Soft light brown stool twice a day

Correct answer: A

Rationale: The correct answer is 'Daily black, sticky stool.' Black sticky stool (melena) is indicative of gastrointestinal bleeding, a serious condition that requires immediate attention from the healthcare provider. Options B and D, 'Daily dark brown stool' and 'Soft light brown stool twice a day,' respectively, represent variations of normal stool characteristics and do not raise immediate concerns about the client's health. Option C, 'Firm brown stool every other day,' suggests constipation, which is of lesser concern and can be managed with interventions.

2. A woman who had a mastectomy is scheduled for a mastectomy peer support visit arranged by her primary health care provider. What is the purpose of the referral?

• A. To teach arm exercises
• B. To prevent social isolation
• C. To meet her physical needs
• D. To view her surgical incision

Correct answer: B

Rationale: The purpose of a mastectomy peer support visit is to prevent social isolation. This visit helps the client maintain her social connections and learn about community resources. Teaching arm exercises and meeting physical needs are tasks for healthcare professionals, not the primary goal of a peer support visit. Viewing the surgical incision is also not the primary purpose of such a visit.

3. A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is most appropriate?

• A. Remind the nurse that family support is important to this family and patient.
• B. Have the nurse explain to the family that too many visitors will tire the patient.
• C. Suggest that the nurse ask family members to leave the room during patient care.
• D. Ask about the nurse's personal beliefs about family support during hospitalization.

Correct answer: D

Rationale: The first step in providing culturally competent care is to understand one's own beliefs and values related to health and health care. Asking the nurse about personal beliefs will help achieve this step. Reminding the nurse that this cultural practice is important to the family and patient will not decrease the nurse's frustration. The remaining responses, such as suggesting that the nurse ask family members to leave the room or having the nurse explain to the family that too many visitors will tire the patient, are not culturally appropriate for this patient.

4. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

• A. Do not worry. Epilepsy can be treated with medications.
• B. The seizure may or may not mean your child has epilepsy.
• C. Since this was the first convulsion, it may not happen again.
• D. Long-term treatment will prevent future seizures.

Correct answer: B

Rationale: The correct response is, 'The seizure may or may not mean your child has epilepsy.' There are various potential causes for a childhood seizure, such as fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic reasons. It's essential not to jump to conclusions about epilepsy based on one seizure. Options A, C, and D provide premature or inaccurate information. Option A may give false reassurance without proper evaluation, option C assumes one seizure guarantees no recurrence, and option D oversimplifies treatment outcomes.

5. The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother-infant bonding?

• A. Asking the mother to change her baby's diaper
• B. Assuring the mother that her baby is receiving excellent care
• C. Encouraging the mother to touch her baby whenever possible
• D. Keeping the mother informed about the care the nursing staff is providing her baby

Correct answer: C

Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother-infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother-infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby's diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.

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