Nursing Elites

1. What is the most effective strategy to assist a client in recognizing and using personal strength?

• A. Encouraging the client's self-identification of strengths.
• B. Promoting the client's active external thinking.
• C. Listening to the client and providing advice as needed.
• D. Assisting the client in maintaining an external locus of control.

Correct answer: A

Rationale: Encouraging the client to identify their own strengths is empowering and helps build self-awareness and self-confidence. This strategy promotes autonomy and self-efficacy, enabling the client to recognize and utilize their personal strengths effectively. Option B, promoting the client's active external thinking, is vague and not directly related to recognizing personal strengths. Option C, listening to the client and providing advice as needed, focuses more on the nurse's role rather than empowering the client to recognize their strengths independently. Option D, assisting the client in maintaining an external locus of control, goes against the goal of helping the client recognize and utilize their internal strengths.

2. A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?

• A. Check with the case manager on duty about possible police intervention.
• B. Provide an environment of concern and emotional stabilization.
• C. Clean the patient's wounds with normal saline and gauze.
• D. Refer the patient to a counselor specializing in trauma.

Correct answer: B

Rationale: In a situation where a patient describes a brutal assault and rape, the first priority should be to provide emotional support and create a safe and supportive environment. This helps the patient feel secure and cared for, which is crucial for their well-being at that moment. Checking with the case manager about police intervention should come after ensuring the patient's immediate emotional needs are addressed. Cleaning the patient's wounds, though important, can be secondary to providing emotional stabilization. Referring the patient to a counselor specializing in trauma is also crucial for long-term support, but the immediate focus should be on providing emotional support and stability.

3. The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?

• A. Set limits and send the client to their room.
• B. Explain to the client that not all people are Christians.
• C. Remove the Bible from the client and explain that they are not "Jesus"?.
• D. Ask the client to share with the group how he knows that he is "Jesus"?.

Correct answer: A

Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.

4. A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?

• A. 36%
• B. 27%
• C. 18%
• D. 9%

Correct answer: C

Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.

5. A healthcare professional is screening patients for immunizations. Which of the following is not a contraindication for immunization?

• A. Seizures
• B. Fever lasting more than 3 days
• C. Malignancy within the past 3 months
• D. Illness lasting more than 6 months

Correct answer: D

Rationale: The correct answer is D, 'Illness lasting more than 6 months.' Chronic conditions lasting more than 6 months are not considered a contraindication for immunization. Choice A, 'Seizures,' can be a contraindication in certain situations, especially if linked to a specific vaccine component. Choice B, 'Fever lasting more than 3 days,' can be a temporary precaution but not a general contraindication. Choice C, 'Malignancy within the past 3 months,' is a contraindication due to the compromised immune system in cancer patients.

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