Nursing Elites

1. 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.

2. The mother of a 5-month-old is being educated about her baby's nutrition by the nurse. Which statement by the mother indicates the need for further teaching?

• A. ''I'm going to try feeding my baby some rice cereal.''
• B. ''When he wakes at night for a bottle, I feed him.''
• C. ''I dip his pacifier in honey so he'll take it.''
• D. ''I keep formula in the refrigerator for 24 hours.''

Correct answer: C

Rationale: The correct answer is ''I dip his pacifier in honey so he'll take it.'' This statement indicates a need for further teaching because honey should be avoided in infants due to the risk of infant botulism. Honey may contain spores of Clostridium botulinum, which can lead to serious illness in infants as they lack the necessary digestive enzymes to eliminate the spores. Feeding rice cereal, responding to night-time feedings, and storing formula in the refrigerator are appropriate practices for infant care, indicating understanding of the instructions.

3. A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client's reaction?

• A. Reflection
• B. Regression
• C. Repudiation
• D. Reconciliation

Correct answer: C

Rationale: The client's reaction of believing that only minor surgery is necessary when faced with the need for an abdominoperineal resection and a colostomy is an example of repudiation. Repudiation involves a refusal to acknowledge anticipated loss as a defense mechanism against the overwhelming stress of illness. The client is psychologically denying the seriousness of the situation. The other choices are incorrect because: - Reflection (Choice A) does not apply since the client is not contemplating the issues of the situation. - Regression (Choice B) is not demonstrated as the client's behavior does not indicate reverting to an earlier stage of development. - Reconciliation (Choice D) is not applicable as the client has not made a realistic adjustment to the illness but rather is in denial of its severity.

4. A terminally ill client repeatedly talks about her son's upcoming wedding and how much she wants to attend. Which stage of the K�bler-Ross theory of death and dying is the client displaying?

• A. Anger
• B. Denial
• C. Bargaining
• D. Acceptance

Correct answer: C

Rationale: The client is displaying the stage of bargaining in the K�bler-Ross theory of death and dying. During the bargaining stage, individuals attempt to negotiate for more time or a different outcome in the face of impending death. In this scenario, the client expressing a desire to attend her son's wedding and discussing it frequently reflects a form of bargaining for additional time to be present for the event. Anger, on the other hand, involves extreme expressions of emotion ranging from irritation to rage. Denial is characterized by an inability to accept the reality of the situation. Acceptance signifies coming to terms with the circumstances and may lead to decreased interest in people and surroundings.

5. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse
• B. Encourage the client to get to the toilet
• C. In a loud voice, call for help
• D. Gently lower the client to the floor

Correct answer: D

Rationale: The priority action for the nurse is to gently lower the client to the floor (Option D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option B) is impractical as the client is already falling. Calling for help in a loud voice (Option C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.

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