Nursing Elites

1. A new mother with class II heart disease tells the nurse that she is afraid her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond?

• A. Suggest that the client arrange for help at home
• B. Ask the client to describe her concerns more fully
• C. Tell the client to speak to her primary health care provider about her concerns
• D. Recommend that the client schedule times when family members can assist her

Correct answer: B

Rationale: When a client expresses fear or concern, it is essential for the nurse to first explore and understand the client's feelings and worries. Asking the client to describe her concerns more fully allows the nurse to gather more information, which is crucial in providing appropriate support and guidance. Suggesting that the client arrange for help at home is presumptuous and may not align with the client's preferences or resources. Telling the client to speak to her primary health care provider shifts the responsibility and does not directly address the client's immediate fears. Recommending that she schedule times when family members can assist her assumes the availability and willingness of family members without addressing the client's emotional needs and fears directly.

2. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?

• A. "I know you're busy, but it's lunchtime."
• B. "Are the voices bothering you again?"
• C. "Get going; you don't want to miss lunchtime."
• D. "It's lunchtime; I'll walk with you to the dining room."

Correct answer: D

Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.

3. Which behavior best indicates that the client has received adequate preparation for the scheduled diagnostic studies?

• A. Asks for the tests to be explained again
• B. Checks the appointment card multiple times
• C. Arrives early and waits quietly to be called for the tests
• D. Paces back and forth in the hallway on the morning of the tests

Correct answer: C

Rationale: The correct answer is arriving early and waiting quietly to be called for the tests. This behavior indicates that the client is prepared, as early arrival suggests an expected degree of anxiety and the quiet waiting indicates a lower level of anxiety and adequate preparation. Asking for the tests to be explained again may signal inadequate explanation, nervousness, or poor memory. Checking the appointment card repeatedly or pacing up and down the hallway indicate a high level of anxiety, which could be associated with inadequate teaching. Nurses providing preprocedural teaching should assess for anxiety related to procedures, coping mechanisms, and retention of information post-teaching. If issues are identified, strategies such as paraphrasing information, having a support person present, seeking advice from someone who has undergone the procedure, or visiting the test center beforehand can be utilized.

4. While planning care for a 2-year-old hospitalized child, which situation would the nurse most likely expect to affect the behavior?

• A. Strange bed and surroundings.
• B. Separation from parents.
• C. Presence of other toddlers.
• D. Unfamiliar toys and games.

Correct answer: B

Rationale: The correct answer is 'Separation from parents.' Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. Choices A, C, and D are incorrect because while strange bed and surroundings, presence of other toddlers, and unfamiliar toys and games may contribute to some level of stress or discomfort, the separation from parents is the primary factor affecting the behavior of a 2-year-old hospitalized child.

5. What is the primary purpose served when an individual takes action to reduce anxiety?

• A. Reduction of tension
• B. Denial of the situation
• C. Avoidance of physical discomfort
• D. Resolution in decision-making

Correct answer: A

Rationale: The primary purpose of taking action to reduce anxiety is to alleviate emotional tension and prevent the exacerbation of anxiety symptoms. By reducing tension, anxiety levels decrease, leading to a sense of comfort, safety, and security. Denial of the situation is not the goal when addressing anxiety; rather, acknowledging and managing it is crucial. While physical discomfort may accompany anxiety, the focus is on alleviating the emotional aspect to mitigate physical manifestations. Although mild anxiety can sometimes improve decision-making skills, higher levels of anxiety typically impede cognitive functions, making resolution in decision-making less likely.

Similar Questions