Nursing Elites

1. A corporate executive works 60-80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions?

• A. structure
• B. relaxation technique
• C. time management
• D. regular exercise

Correct answer: C

Rationale: The correct answer is 'relaxation technique.' Biofeedback techniques are a form of relaxation technique that can help individuals quiet the mind, release tension, and counteract responses to stress. Teaching biofeedback techniques to the client aims to promote relaxation and stress management. Choice A, 'structure,' does not directly relate to teaching biofeedback techniques. Choice C, 'time management,' focuses on organizing tasks efficiently, not on relaxation techniques. Choice D, 'regular exercise,' although beneficial for overall health, is not specifically related to the teaching of biofeedback techniques for stress relief.

2. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for:

• A. Nasal congestion
• B. Abdominal tenderness
• C. Muscle tetany
• D. Oliguria

Correct answer: A

Rationale: During the removal of a pituitary tumor using the transsphenoidal approach, nasal congestion is a significant concern as it can further obstruct the airway. This can be due to mucosal swelling, bleeding, or edema resulting from the surgery. Nasal congestion requires immediate attention to prevent airway compromise. Abdominal tenderness, muscle tetany, and oliguria are not directly associated with the pituitary gland or the transsphenoidal approach, making them incorrect choices. Abdominal tenderness is more common in abdominal or pelvic surgeries due to intra-abdominal issues. Muscle tetany is related to electrolyte imbalances or neuromuscular disorders, not specific to pituitary surgery. Oliguria is a concern in renal-related conditions, not typically in pituitary tumor surgeries.

3. While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?

• A. Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
• B. Disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
• C. Return to their own unit and not disclose that confidential information has been overheard.
• D. Ignore the situation.

Correct answer: A

Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.

4. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?

• A. Telling the client that the medication will need to be taken with juice
• B. Telling the client that the medication will change the color of the urine
• C. Telling the client to take the medication before going to bed at night
• D. Telling the client to take the medication if night sweats occur

Correct answer: B

Rationale: The correct answer is telling the client that the medication will change the color of the urine. Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is important as the client might think this is a complication. Answer A is incorrect because there is no specific requirement to take rifampin with juice. Answer C is incorrect because rifampin should be taken at consistent times, not necessarily before going to bed. Answer D is incorrect as rifampin should be taken regularly as prescribed, not based on symptoms like night sweats.

5. A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?

• A. "You have nothing to worry about. You are in a safe place. Try to relax."?
• B. "Has anything happened recently or in the past that might have triggered these feelings?"?
• C. "We have given you a medication that helps to decrease feelings of anxiety."?
• D. "Take some deep breaths and try to calm down."?

Correct answer: B

Rationale: Choice B is the best response as it shows empathy, acknowledges the patient's feelings, and opens the door for discussion about potential triggers for anxiety. This approach helps the patient explore the root cause of his anxiety and provides an opportunity for therapeutic communication. Choice A dismisses the patient's feelings and offers false reassurance, which may not address the underlying issue. Choices C and D do not encourage the patient to express his emotions or delve into the reasons behind his anxiety, hindering the therapeutic process.

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