Nursing Elites

1. A client in a long-term care facility tells the nurse, 'My daughter never visits me.' The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?

• A. Empathy
• B. Self-disclosure
• C. Disapproval
• D. False reassurance

Correct answer: B

Rationale: Self-disclosure is a therapeutic communication technique that nurses use to build rapport and trust with clients. By sharing personal experiences, nurses can help clients feel understood and encourage them to open up. In this scenario, the nurse sharing her own struggle with visiting her mother demonstrates self-disclosure. Empathy (choice A) involves understanding and sharing the feelings of another, but in this case, the nurse is sharing her own experience rather than focusing solely on the client's emotions. Disapproval (choice C) and false reassurance (choice D) do not apply in this context as the nurse is not expressing disapproval or giving false hope or comfort.

2. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.

3. A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?

• A. Contact the state board of nursing licensure to report the offense
• B. Review the state scope of practice standards for nurses
• C. Ask another nurse to perform the task to learn the procedure
• D. Contact the house supervisor to make the decision on whether the nurse should perform the task

Correct answer: B

Rationale: When faced with a task that a nurse believes may be beyond their scope of practice, it is essential to refer to the state's specific scope of practice standards for nurses. This step is crucial as these standards can vary between states, providing clarity on what tasks are permissible. By reviewing these standards, the nurse can determine if the task falls within their scope of practice. Contacting the state board of nursing licensure to report the offense (Choice A) is premature and should only be considered if there is a serious violation after reviewing the scope of practice. Asking another nurse to perform the task (Choice C) does not address the issue of clarifying the scope of practice. Contacting the house supervisor (Choice D) may be necessary if the nurse cannot determine the appropriateness of the task based on the scope of practice standards.

4. A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?

• A. Knowledge Deficit related to post-partum blood loss
• B. Self-Care Deficit related to post-partum neglect
• C. Fluid Volume Deficit related to post-partum hemorrhage
• D. Body Image Disturbance related to body changes after delivery

Correct answer: C

Rationale: The correct nursing diagnosis in this situation is 'Fluid Volume Deficit related to post-partum hemorrhage.' Post-partum hemorrhage can lead to excessive bleeding, putting the client at risk of fluid volume deficit due to the loss of blood volume. This diagnosis is most appropriate as it addresses the immediate concern of fluid loss. 'Knowledge Deficit related to post-partum blood loss' (Choice A) is incorrect as the priority in this case is addressing the physical issue of fluid volume deficit rather than knowledge deficit. 'Self-Care Deficit related to post-partum neglect' (Choice B) is not relevant to the situation described. 'Body Image Disturbance related to body changes after delivery' (Choice D) is not the most appropriate nursing diagnosis in this context where the primary concern is fluid volume deficit due to post-partum hemorrhage.

5. Working in a clinic located in a community with many Hispanics, what strategy could the nurse implement to decrease health care disparities for Hispanic patients?

• A. Improve public transportation to the clinic.
• B. Update equipment and supplies at the clinic.
• C. Obtain low-cost medications for clinic patients.
• D. Teach clinic staff about Hispanic health beliefs.

Correct answer: D

Rationale: Health care disparities are primarily rooted in stereotyping, biases, and prejudice among healthcare providers. By educating clinic staff about Hispanic health beliefs, the nurse can help combat these issues, leading to improved cultural competency and patient care. Understanding the cultural context of Hispanic patients can enhance communication, trust, and treatment adherence. Improving public transportation, updating equipment, and obtaining low-cost medications are important aspects of healthcare delivery but do not directly address the underlying causes of health disparities experienced by Hispanic patients.

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