Nursing Elites

1. A man expresses surprise that his wife has become very withdrawn during hospitalization for pneumonia. Which response helps the husband understand how some people cope with hospitalization?

• A. "Hospitalization might cause a crisis. Has your wife had to cope with problems before this?"?
• B. "Some people react that way. She will be more talkative when she feels better."?
• C. "Your wife might be feeling concern that she cannot fulfill her normal roles."?
• D. "This is typical behavior for someone who is as ill as your wife."?

Correct answer: A

Rationale: The correct response acknowledges that hospitalization can lead to a crisis for both patients and their families. By asking if the wife has coped with problems before, it opens up a dialogue about her coping mechanisms and past experiences. This can help the husband understand his wife's current behavior better and provide valuable insights. Choices B, C, and D do not directly address the potential crisis that hospitalization can cause or inquire about the wife's coping strategies, making them less effective responses.

2. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?

• A. A client with brain attack (stroke) receiving tube feedings
• B. A client with congestive heart failure complaining of nighttime dyspnea
• C. A client who had a thoracotomy 6 months ago
• D. A client with Parkinson’s disease

Correct answer: B

Rationale: The correct answer is B. The client with congestive heart failure complaining of nighttime dyspnea should be seen first as airway management is a priority in nursing care. This client's symptoms indicate potential respiratory distress, requiring immediate attention. Choices A, C, and D involve clients who are more stable and do not present with urgent or acute conditions that require immediate intervention. Choice A with a client receiving tube feedings for a stroke may require attention, but the urgency of addressing potential respiratory distress in choice B takes precedence. Choice C, a client who had a thoracotomy 6 months ago, unless presenting with acute distress, does not necessitate immediate attention. Choice D, a client with Parkinson's disease, is usually a chronic condition that does not typically require immediate intervention for the described scenario.

3. A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:

• A. Actual Chronic Low Self-Esteem (related to obesity).
• B. Potential Chronic Low Self-Esteem (related to obesity).
• C. Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
• D. Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).

Correct answer: D

Rationale: In this scenario, the client's recent weight loss and subsequent pregnancy could lead to concerns about weight regain and body image. The most appropriate nursing diagnosis is 'Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).' This diagnosis reflects the client's potential emotional response to the fear of losing the progress achieved through weight loss and dealing with changes in body image due to pregnancy. Options A and C imply that low self-esteem is already present, which is not supported by the information given. Option B is not as suitable as the client's self-esteem issues are more related to the fear of weight regain and pregnancy, making option D the best choice.

4. To ensure safety while administering a nitroglycerine patch, what should the nurse do?

• A. Wear gloves
• B. Shave the area where the patch will be applied
• C. Wash the area thoroughly with soap and rinse with hot water
• D. Apply the patch to the buttocks

Correct answer: A

Rationale: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.

5. A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?

• A. an inflammatory process of the extrahepatic bile ducts
• B. an arrest of the normal flow of bile
• C. an inflammation of the gallbladder
• D. the formation of gallstones

Correct answer: B

Rationale: Cholestasis due to TPN administration is an intrahepatic process that interrupts the normal flow of bile. It is characterized by a reduction or stoppage of bile flow. Choice A, an inflammatory process of the extrahepatic bile ducts, refers to cholangitis, not cholestasis. Choice C, an inflammation of the gallbladder, describes cholecystitis, a different condition. Choice D, the formation of gallstones, is not correct as cholestasis is about the flow of bile, not the formation of gallstones.

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