Nursing Elites

1. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

• A. Blood pressure monitoring every 15 minutes
• B. Insertion of a Levine tube
• C. Continuous cardiac monitoring
• D. Administration of pain medication every 4 hours

Correct answer: B

Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.

2. A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic self-expectations) is when the client can:

• A. report a positive self-concept.
• B. identify negative thoughts.
• C. recognize positive thoughts.
• D. give one positive cue with each negative cue

Correct answer: A

Rationale: The correct answer is to 'report a positive self-concept.' The problem statement is Negative Self-Concept, so the goal is for the client to achieve a positive self-concept. This involves helping the client recognize their worth and strengths. Choices B, C, and D do not directly address the resolution of Negative Self-Concept. Identifying negative thoughts (B) is a step towards improvement but does not represent a successful resolution. Recognizing positive thoughts (C) is positive but not the primary goal in addressing Negative Self-Concept. 'Give one positive cue with each negative cue' (D) is not as comprehensive as achieving an overall positive self-concept.

3. To decrease a client's use of denial and increase the client's expression of feelings, what should the nurse do?

• A. Tell the client to stop using the defense mechanism of denial
• B. Positively reinforce each expression of feelings
• C. Instruct the client to express feelings
• D. Challenge the client each time denial is used

Correct answer: B

Rationale: The most appropriate approach to decrease a client's use of denial and promote the expression of feelings is to positively reinforce each expression of feelings. This method helps the client feel supported and validated, encouraging them to continue expressing their emotions openly. Positively reinforcing the expression of feelings can help reduce the need for denial as the client learns that their emotions are acknowledged and accepted. Choices A, C, and D are incorrect. Choice A of telling the client to stop using denial is too directive and may be ineffective. Instructing the client to express feelings (Choice C) lacks positive reinforcement, and challenging the client each time denial is used (Choice D) can create a confrontational environment that hinders therapeutic progress.

4. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's

• A. feelings about what has been described.
• B. thoughts about what has been described.
• C. possible solutions to the problem.
• D. intent in sharing the description.

Correct answer: B

Rationale: In performing a psychosocial assessment, the nurse follows a structured approach, starting with encouraging the client to describe problematic behaviors and situations. The next step is to elicit the client's thoughts about what has been described. This step helps gather more assessment data and understand how the client interprets the situation. Asking about feelings, exploring possible solutions, and understanding the client's intent in sharing the description are more complex processes that come later in the assessment. Therefore, the correct next step after describing behaviors and situations is to inquire about the client's thoughts.

5. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?

• A. "I should avoid eating foods that produce gas."?
• B. "I should drink more fluids like water and non-caffeinated fruit juices."?
• C. "I should set a regular schedule for bowel movements."?
• D. "I should sit in an upright position for bowel movements."?

Correct answer: B

Rationale: The corrected statement indicates the need for further teaching because it suggests consuming fluids like fruit juices, which can include caffeinated options that may stimulate fluid loss through increased urination. It is more appropriate to emphasize the consumption of fluids like water and non-caffeinated fruit juices for proper hydration. Choices A, C, and D demonstrate a correct understanding of bowel management by focusing on dietary considerations, establishing a regular bowel movement schedule, and using proper positioning during bowel movements. Option B is incorrect as it may lead to increased fluid loss due to caffeine content in some fruit juices.

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