Nursing Elites

1. A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?

• A. "You can receive a sedative to help you relax during the test."?
• B. "There is absolutely nothing to worry about."?
• C. "There is no discomfort with this test, so don't be anxious."?
• D. "The test won't last long, so you can handle it."?

Correct answer: A

Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety. Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress. Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.

2. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

• A. history of dizziness
• B. need for a wheelchair due to reduced mobility
• C. weakness and fatigue noted when climbing stairs
• D. intact recent and remote memory

Correct answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.

3. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?

• A. Accepting responsibility for the actions of others
• B. The official power to ensure that an organizational decision is enforced
• C. Bearing the legal responsibility for others' performance of tasks
• D. Taking responsibility for what staff members do

Correct answer: B

Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others' performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.

4. A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the health care provider, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?

• A. Stating to the health care provider, 'I don't really care whether you report me. I am not writing your prescriptions.'
• B. Fulfilling the health care provider's request
• C. Discussing the situation with the nurse manager
• D. Reporting the health care provider to the chief of medicine at the hospital

Correct answer: C

Rationale: When a conflict arises, it is most appropriate to try resolving the conflict directly. In this situation, the nurse has tried to explain why she is uncomfortable with the health care provider's request but has been unable to resolve the conflict. The nurse would then most appropriately use organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the health care provider or seek assistance from the nursing supervisor. Fulfilling the health care provider's request and writing the prescriptions in the clients' charts ignores the issue. Reporting the health care provider to the chief of medicine is inappropriate because the nurse should use the appropriate organizational channels of communication to resolve the conflict. Stating 'I don't really care whether you report me. I am not writing your prescriptions.' is an inappropriate statement and will result in further conflict between the nurse and health care provider.

5. A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?

• A. The immune system of an infant is immature, and the infant is at risk for infection.
• B. The transfer of your antibodies protects your infant until the infant is 12 months old.
• C. Yes, your infant is protected from all infections.
• D. If you breastfeed, your infant is protected from infection.

Correct answer: A

Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.

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