Nursing Elites

1. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

• A. Instruct in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique to change the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

2. A 20-year-old young adult has been recently admitted to the hospital. According to Erikson, which of the following stages is the adult in?

• A. Trust vs. mistrust
• B. Initiative vs. guilt
• C. Autonomy vs. shame
• D. Intimacy vs. isolation

Correct answer: D

Rationale: The young adult, at 20 years old, is in the stage of Intimacy vs. Isolation according to Erikson's psychosocial theory. This stage typically occurs during young adulthood, between the ages of approximately 19 and 40. The primary conflict in this stage revolves around the development of intimate, loving relationships with others. This stage focuses on establishing close bonds and connections with others, seeking emotional closeness and commitment. Choices A, B, and C are incorrect. Trust vs. mistrust is the stage that occurs in infancy, Initiative vs. guilt is in early childhood, and Autonomy vs. shame is in toddlerhood. These stages each represent different developmental challenges and conflicts that individuals face at various points in their lives.

3. When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?

• A. ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
• B. ''Smoking and not doing the exercises will make your lung disease continue to get worse.''
• C. 'I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
• D. ''Your shortness of breath is probably because of your smoking and not doing the exercises.''

Correct answer: A

Rationale: Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.

4. A 17-year-old Asian client is being seen for lower abdominal pain in the right quadrant. The client is accompanied by his parents. The nurse notes that the client's father does not make eye contact and shows little response when told that the client will need surgery. Which of the following is the most appropriate action of the nurse?

• A. Contact an interpreter to give the information again in the father's native language
• B. Continue to provide information about surgery to both the client and his parents
• C. Call social services to evaluate the parent's standard of care
• D. Contact the physician about postponing the surgery

Correct answer: B

Rationale: Nurses may work with clients who have varying cultural beliefs. Because of this, nurses must remain aware of the cultural practices associated with certain ethnic groups. Asian Americans may avoid eye contact as a sign of respect; additionally, emotional responses may be avoided except for in private situations. If this family did not have a language barrier, the nurse should continue to provide appropriate information about the surgery and recognize the cultural differences that exist. Contacting an interpreter is not necessary as there was no mention of a language barrier. Calling social services to evaluate the parent's standard of care is premature and not within the nurse's immediate scope of practice. Contacting the physician about postponing the surgery is not warranted based on the information provided.

5. The client with cholecystitis is being instructed about dietary choices. Which meal best meets the dietary needs of this client?

• A. Steak, baked beans, and a salad
• B. Broiled fish, green beans, and an apple
• C. Pork chops, macaroni and cheese, and grapes
• D. Avocado salad, milk, and angel food cake

Correct answer: B

Rationale: Clients with cholecystitis, which is inflammation of the gallbladder, should follow a low-fat diet to reduce symptoms. Broiled fish, green beans, and an apple (Option B) is the most suitable choice as it is low in fat. Steak, baked beans, and a salad (Option A) provide a high amount of fat and protein, which may exacerbate symptoms of cholecystitis. Pork chops, macaroni and cheese, and grapes (Option C) and avocado salad, milk, and angel food cake (Option D) contain high-fat foods that are not recommended for individuals with cholecystitis. Therefore, Option B is the most appropriate choice for a client with cholecystitis.

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