Nursing Elites

1. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

2. A client in the second trimester of pregnancy asks how to treat constipation. Which of the following should the nurse recommend?

• A. Decrease intake of vitamins and supplements to every other day
• B. Eat 15 g of fiber per day
• C. Consume 48 ounces of water daily
• D. Drink hot water with lemon juice each morning

Correct answer: D

Rationale: The correct answer is D: Drink hot water with lemon juice each morning. Drinking hot water with lemon juice can help stimulate bowel movements, making it a natural and safe recommendation for pregnant clients experiencing constipation. Choice A is incorrect because reducing vitamin and supplement intake may not directly address constipation. Choice B, eating 15 g of fiber per day, could be helpful but may not be as effective as the correct answer for immediate relief. Choice C, consuming 48 ounces of water daily, is essential for overall health but may not be as directly effective as the correct answer in alleviating constipation.

3. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

• A. Apologize to the others for your behavior.
• B. I am disappointed that you continue to act out when you are angry.
• C. Come outside with me for a walk.
• D. If you don't calm down, you will have to go into seclusion.

Correct answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

4. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges
• B. Cleanse the wound with normal saline
• C. Don sterile gloves
• D. Determine the client's pain level

Correct answer: D

Rationale: The correct answer is to determine the client's pain level first. Assessing the client's pain is crucial before proceeding with any procedure, including dressing changes. This step ensures that appropriate pain management measures can be implemented, making the wound care process as comfortable as possible for the patient. Applying skin preparation to wound edges (choice A) can come after addressing the pain. While cleansing the wound with normal saline (choice B) and donning sterile gloves (choice C) are important steps in wound care, they should follow the assessment of the client's pain level to prioritize the patient's comfort and well-being.

5. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused
• B. Request a prescription for PRN restraints when the client is wandering
• C. Dim the lighting in the client’s room
• D. Leave one side rail up on the client's bed

Correct answer: D

Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.

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