Nursing Elites

1. A female nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the nurse to intervene if she takes which action?

• A. The nurse explains the 0 to 10 intensity pain scale.
• B. The nurse asks the patient when the headaches started.
• C. The nurse sits down at the bedside and closes the privacy curtain.
• D. The nurse calls for a male nurse to bring a hospital gown to the room.

Correct answer: C

Rationale: In some Arab cultures, it is not considered appropriate for a male to be alone with a female who is not his spouse. Therefore, it is important for the nurse to respect the patient's cultural beliefs and privacy by ensuring that a female nurse is not alone with the male patient. Sitting down at the bedside and closing the privacy curtain could potentially lead to a situation where the nurse is alone with the patient, which goes against the patient's cultural norms. The other actions, such as explaining the pain scale, asking about the onset of headaches, and requesting a male nurse to bring a hospital gown, are all appropriate and do not conflict with the patient's cultural beliefs.

2. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

• A. Encourage the client to see the clinic's grief counselor.
• B. Determine if the client has a family history of suicide attempts.
• C. Inquire about whether the life partner was suffering from AIDS.
• D. Consult with the health care provider about the client's need for antidepressant medications.

Correct answer: A

Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is relevant but is not a high-priority intervention compared to addressing the immediate grief support needs of the client. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. While antidepressant medication might be necessary based on further assessment, grief counseling is a more appropriate initial action as grief is a typical response to the loss of a loved one.

3. A client is discussing his personal feelings of self-esteem and self-concept with a nurse. Which of the following questions is most appropriate for assessing the client's personal identity?

• A. What is your educational background?
• B. Are your parents still living?
• C. What do you like about your life right now?
• D. Where do you see yourself in 10 years?

Correct answer: C

Rationale: When assessing a client's personal identity, it is essential for the nurse to inquire about aspects related to the client's self-perception and self-worth. Asking about what the client likes about his current life helps to explore his positive self-perceptions and areas of contentment. This question encourages the client to reflect on his present circumstances and identify aspects that contribute to his sense of personal identity. Choices A, B, and D are not as relevant for assessing personal identity as they focus on educational background, parental status, and future aspirations, respectively, rather than directly addressing the client's current self-perception and identity.

4. Which characteristic is associated with anorexia nervosa?

• A. Manic
• B. Rebellious
• C. Hypoactive
• D. Perfectionistic

Correct answer: D

Rationale: Individuals with anorexia nervosa often exhibit perfectionistic traits, characterized by rigid standards and extreme self-discipline as a way to maintain control and fulfill personal and societal expectations. The focus on achieving an ideal body image through strict dietary habits and excessive exercise is a common manifestation of this perfectionism. The incorrect choices are: A) 'Manic' is not typically associated with anorexia nervosa; individuals with this disorder are more likely to experience anxiety and depression. B) 'Rebellious' does not align with the usual behavior seen in individuals with anorexia nervosa, who tend to comply with societal expectations rather than rebel against them. C) 'Hypoactive' does not describe the characteristic behavior of individuals with anorexia nervosa, who often engage in excessive physical activity as a means of weight loss.

5. When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?

• A. ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
• B. ''Smoking and not doing the exercises will make your lung disease continue to get worse.''
• C. 'I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
• D. ''Your shortness of breath is probably because of your smoking and not doing the exercises.''

Correct answer: A

Rationale: Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.

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