Nursing Elites

1. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?

• A. External light sources may cause falsely high oximetry values
• B. A bright light in the client's face may cause a low pulse oximetry
• C. External light sources may cause falsely low oximetry values
• D. The client needs a dark and quiet room to recover and maintain proper oxygenation

Correct answer: A

Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.

2. A nurse is caring for an in-patient client in the hospital who is from another country and who fasts for temporary periods in order to promote his own spiritual growth. The nurse responds by saying, 'You need to eat something while you are here. Food and proper nutrition are extremely important for your health.' What social philosophy is the nurse demonstrating?

• A. Ethnocentrism
• B. Relativism
• C. Stereotyping
• D. Xenocentrism

Correct answer: A

Rationale: The nurse's response reflects ethnocentrism, a belief that one's own cultural practices are superior to others. Ethnocentrism involves viewing one's own culture as the standard by which all others should be judged. In this scenario, the nurse's insistence that the client needs to eat disregards the client's cultural and spiritual beliefs, considering only the nurse's perspective as valid. B: Relativism is the recognition and acceptance of cultural differences without judgment. The nurse's behavior does not align with relativism as there is a lack of understanding and acceptance of the client's cultural practices. C: Stereotyping involves making assumptions about individuals based on predefined characteristics. While the nurse may have made assumptions, the core issue in this scenario is the belief in the superiority of one's own cultural practices. D: Xenocentrism is the opposite of ethnocentrism, where one perceives other cultures as superior to their own. The nurse's actions are not driven by a belief in the superiority of the client's culture but rather by a belief in the superiority of her own cultural practices.

3. How can the dangers associated with wandering in Alzheimer's disease patients be prevented?

• A. Bed alarms
• B. Chair alarms
• C. Door alarms
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'All of the above.' Bed alarms, chair alarms, and door alarms are all effective measures to prevent the dangers associated with wandering in Alzheimer's disease patients. These alarms can alert caregivers when a patient tries to leave a designated area, helping to keep them safe. It is crucial to respond promptly to these alarms to ensure the patient's safety. Choices A, B, and C are incorrect individually as each type of alarm plays a vital role in a comprehensive wandering prevention strategy.

4. What is involved in obtaining informed consent?

• A. An explanation of the reasons for the procedure
• B. A signature on a form indicating the client agrees to the procedure
• C. A statement affirming liability if complications arise during the procedure
• D. Both A and C

Correct answer: A

Rationale: Informed consent involves providing the client with an explanation of the reasons for the procedure, the potential risks, benefits, and available alternatives. It is essential for the healthcare provider to ensure that the client understands the information provided before agreeing to the procedure. While obtaining a signature on a consent form is part of the process, it is not the sole indicator of informed consent. Option C, which mentions liability statements, is incorrect as informed consent focuses on ensuring the client understands the procedure, not on affirming liability. Therefore, the correct answer is the explanation of the reasons for the procedure.

5. Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:

• A. Auditory hallucinations
• B. Bizarre behaviors
• C. Ideas of reference
• D. Motivation for activities

Correct answer: D

Rationale: In clients with negative symptoms of schizophrenia, such as Jaime, a common problem is avolition, which is the lack of motivation for activities. These 'negative' symptoms are characterized by inexpressive faces, blank looks, monotone speech, few gestures, and a seeming lack of interest in the world. Patients may also experience an inability to feel pleasure or act spontaneously. It is crucial to differentiate between the lack of expression and lack of feeling, as well as between lack of will and lack of activity. Auditory hallucinations (choice A) are positive symptoms, not typically associated with negative symptoms of schizophrenia. Bizarre behaviors (choice B) are more aligned with positive symptoms like disorganized behavior. Ideas of reference (choice C) involve incorrectly interpreting casual incidents and external events as having direct reference to oneself, which is not directly related to motivation for activities seen in negative symptoms.

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