Nursing Elites

1. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose � Volume on hand) / Dose on hand). In this case, it would be (4 mg � 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.

2. When attempting to incorporate the Latino client's cultural background into the plan of care, which consideration is the most important?

• A. Socioeconomic considerations regarding hospitalization
• B. The meaning and attention the client places on the future
• C. The client's need to control care to ensure desired outcomes
• D. Inclusion of the family in the plan of care with the client's permission

Correct answer: D

Rationale: The most important consideration when incorporating the Latino client's cultural background into the plan of care is the inclusion of the family in the care plan with the client's permission. In Latino cultures, family plays a vital role, and there is a strong emphasis on family support during challenging times. This support can positively impact the client's health outcomes and overall well-being. Socioeconomic status, although relevant, does not carry more weight than usual in healthcare decisions. Latino clients typically focus on the present rather than the future, and they often attribute outcomes to external factors like fate or divine intervention. While the client's need for control is important, involving the family aligns more closely with the cultural values and preferences of Latino clients.

3. While receiving a preoperative enema, a client starts to cry and says, 'I'm sorry you have to do this messy thing for me.' Which is the nurse's best response?

• A. I don't mind it.'
• B. 'You seem upset.'
• C. 'This is part of my job.'
• D. 'Nurses get used to this.'

Correct answer: B

Rationale: The nurse's best response in this situation is to acknowledge the client's emotional state, as it shows empathy and encourages further expression of feelings. Choice A, 'I don't mind it,' dismisses the client's emotions and does not address the underlying issue. Choice C, 'This is part of my job,' focuses on the task rather than the client's emotional needs. Choice D, 'Nurses get used to this,' minimizes the client's feelings and lacks empathy. By selecting choice B, 'You seem upset,' the nurse acknowledges the client's distress and opens the door for further communication and support.

4. During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practices?

• A. Spiritual beliefs
• B. Family practices
• C. Emotional factors
• D. Cultural background

Correct answer: B

Rationale: The correct answer is 'Family practices.' In this scenario, the client's health practices are influenced by the fact that her family members never had annual gynecologic examinations, leading her to believe that such preventive care measures are unnecessary. This highlights the impact of familial behavior on an individual's perception of healthcare. Spiritual beliefs are not the primary factor at play here; they may affect the choice of medical treatment but not the decision to seek preventive care. Emotional factors like stress or fear could influence health practices, but there is no indication of this in the client's case. Cultural background would come into play if the client followed specific health beliefs or customary practices related to illness and health restoration.

5. Which therapeutic approach would indicate the client is receiving desensitization therapy?

• A. Imagery
• B. Modeling
• C. Role playing
• D. Assertiveness training

Correct answer: A

Rationale: The correct answer is 'Imagery.' Imagery is a therapeutic approach used in desensitization therapy. It helps in facilitating positive self-talk and involves the client initiating and controlling mental pictures to correct faulty cognitions. Modeling, role-playing, and assertiveness training are effective general behavioral approaches but are not specific to desensitization therapy.

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