Nursing Elites

1. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client’s care.
• B. Provide the wife with information about hospice.
• C. Encourage the wife to visit during and after painful treatments are completed.
• D. Refer the wife to a support group for family members of those dying of cancer.

Correct answer: A

Rationale: During this challenging time of dealing with a terminal cancer diagnosis, involving the wife in the care process can be highly beneficial. By asking the wife how she would like to participate in the client’s care, it allows her to feel more in control and connected. This approach fosters a collaborative care environment, ensuring that the wife's preferences and needs are taken into consideration. Providing information about hospice (choice B) may be premature at this stage and could potentially overwhelm the family. Encouraging the wife to visit during and after painful treatments (choice C) may not address her need for involvement in decision-making. Referring the wife to a support group (choice D) is helpful but may not directly involve her in the care process of her husband.

2. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?

• A. Determine the client’s sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: D

Rationale: Teaching coping strategies is an appropriate first intervention for a client experiencing sleep difficulties and stress. It can help manage stress and improve sleep without immediately resorting to medication. By teaching coping strategies, the nurse empowers the client to address the underlying issues contributing to his sleep problems rather than just providing a temporary solution. Referring for a sleep study and neurological follow-up may be considered later if the client's sleep issues persist despite implementing coping strategies. Determining the client’s sleep and activity pattern may be helpful but addressing coping strategies is more beneficial in managing stress-related sleep issues. Obtaining a prescription for the client to take when stressed does not address the root cause of the sleep problem and may lead to dependency on medication rather than promoting long-term solutions.

3. By rolling contaminated gloves inside-out, the healthcare professional is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When contaminated gloves are rolled inside-out, they are serving as a mode of transmission by carrying pathogens from the reservoir's portal of exit to a new portal of entry. This action increases the risk of transmitting infections from one person to another, emphasizing the importance of proper glove removal techniques to prevent the spread of pathogens. Choices B, C, and D are incorrect in this context. Portal of entry refers to the route through which a pathogen enters a susceptible host, reservoir is the habitat where the pathogen lives, grows, and multiplies, and portal of exit is the path through which a pathogen leaves its host.

4. What is the main purpose of the working phase of the nurse-patient relationship?

• A. Establish a formal or informal contract that addresses the patient's problems.
• B. Implement nursing interventions that are designed to achieve expected patient outcomes.
• C. Develop rapport and trust so the patient feels supported, and the initial plan can be identified.
• D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.

Correct answer: B

Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship. Choices A, C, and D are incorrect as they describe activities more aligned with other phases of the nurse-patient relationship, such as orientation and introductory phases.

5. After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?

• A. Is voiding normally.
• B. Has urinary retention.
• C. Has developed renal failure.
• D. Needs an indwelling catheter.

Correct answer: B

Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying. Choice A is incorrect because voiding normally would indicate a larger amount of urine output. Choice C is incorrect as renal failure would typically present with other signs and symptoms. Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.

Similar Questions