Nursing Elites

1. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?

• A. Images indicate the presence of tumors and scars.
• B. The scan clearly outlines structures of the brain.
• C. Results show activity in various portions of the brain.
• D. PET shows biochemical levels of neurotransmitters.

Correct answer: C

Rationale: The correct answer is C. PET scans are primarily used to detect and observe the metabolic activity in various parts of the brain. This helps in diagnosing conditions related to brain function, such as tumors, brain disorders, and overall brain activity. Choices A, B, and D are incorrect because PET scans focus on metabolic activity and functions in the brain rather than solely indicating the presence of tumors, outlining brain structures, or showing biochemical levels of neurotransmitters.

2. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred?

• A. Is worried about losing his job to a woman
• B. Tortured animals as a child
• C. Was physically abused by his mother
• D. Hates to be touched by anyone

Correct answer: C

Rationale: The correct answer is C: 'Was physically abused by his mother.' A history of physical abuse can lead to heightened responses to physical contact. In this scenario, the employee's reaction of becoming very angry and swinging at the female employee after being pushed may be influenced by past experiences of physical abuse. This history can contribute to increased sensitivity to physical interactions and may trigger defensive or aggressive responses. Choices A, B, and D are less directly related to the employee's reaction in this specific context. While worrying about losing his job to a woman could contribute to underlying stress or insecurity, torturing animals as a child reflects a different type of behavioral issue, and hating to be touched by anyone suggests personal boundaries unrelated to the observed behavior in this scenario.

3. The nurse is caring for a client who is experiencing a panic attack. Which intervention should the nurse implement first?

• A. Stay with the client and remain calm.
• B. Encourage the client to express their feelings.
• C. Teach the client deep-breathing exercises.
• D. Administer prescribed anti-anxiety medication.

Correct answer: A

Rationale: The priority intervention is to stay with the client and remain calm (A). This provides immediate support and reassurance. Encouraging the client to express their feelings (B) and teaching deep-breathing exercises (C) are important but should come after ensuring the client's immediate safety and comfort. Administering medication (D) might be necessary, but the nurse should first focus on providing a calming presence to help the client feel safe and supported during the panic attack.

4. The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?

• A. Provide detailed explanations during wound cleansing.
• B. Perform the dressing change in a non-judgmental manner.
• C. Ask the client non-threateningly why they cut their abdomen.
• D. Request assistance from another staff member for the dressing change.

Correct answer: B

Rationale: Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder who has self-inflicted injuries. This approach helps build trust, reduces feelings of shame or guilt, and fosters a therapeutic relationship. Choice A is incorrect because while detailed explanations may be necessary, the focus should be on the non-judgmental approach. Choice C is inappropriate as it may come across as accusatory or threatening, potentially worsening the client's emotional state. Choice D is not the best option as the RN should strive to handle the situation themselves in a supportive and empathetic manner.

5. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?

• A. Sit down in a chair near the client.
• B. Position self within an arm's length of the client.
• C. Ensure that there is physical space between the nurse and client.
• D. Move to a position that allows the client to be closest to the room's door.

Correct answer: C

Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.

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