Nursing Elites

1. A nurse is caring for a client in a mental health facility. The client’s daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response?

• A. I’d like to know more about what’s bothering you.
• B. Why are you feeling this way?
• C. You did the right thing by bringing him here.
• D. I’m sure your father doesn’t blame you.

Correct answer: A

Rationale: The correct response is A: 'I’d like to know more about what’s bothering you.' Encouraging the daughter to express her feelings allows her to explore her emotions, which can be helpful in addressing her guilt and providing emotional support. Choice B is not as open-ended and may come across as confrontational. Choice C may invalidate the daughter's feelings of guilt by implying she shouldn't feel that way. Choice D assumes the father's emotions and may not address the daughter's feelings of guilt effectively.

2. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?

• A. Wear an N95 respirator mask when caring for the client.
• B. Place the client in a semi-private room.
• C. Have the client wear a surgical mask during meals.
• D. Use a negative pressure air filtration system.

Correct answer: A

Rationale: The correct answer is to wear an N95 respirator mask when caring for the client with TB. This is crucial to prevent the nurse from inhaling the airborne particles that spread the infection. Choice B is incorrect because placing the client in a semi-private room does not address the protection of the nurse. Choice C is incorrect as having the client wear a surgical mask during meals is not sufficient to protect the nurse during all interactions. Choice D is incorrect as using a negative pressure air filtration system is more applicable to airborne infection isolation rooms in healthcare settings and not a standard intervention for nurses caring for a single client with TB.

3. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Offer advice on coping strategies
• B. Encourage the partner to ask for help when needed
• C. Discuss the importance of grieving alone
• D. Suggest the partner avoid talking about the loss

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

4. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign?

• A. After stroking the lateral area of the foot, the client’s toes contract and draw together
• B. After hip flexion, the client is unable to extend their leg completely without pain
• C. The client’s voluntary movement is not coordinated
• D. The client reports pain and stiffness when flexing their neck

Correct answer: B

Rationale: A positive Kernig’s sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding indicates meningeal irritation. Choices A, C, and D do not describe Kernig’s sign. Choice A describes a normal plantar reflex, choice C refers to coordination issues, and choice D describes neck pain and stiffness, which are not specific to Kernig’s sign.

5. A nurse on the medical-surgical unit is receiving reports on four clients. Which of the following clients should the nurse assess first?

• A. A client who is receiving warfarin and has an INR of 3.3
• B. A client who has acute kidney injury, creatinine 4 mg/dL, and BUN 52 mg/dL
• C. A client who had an NG tube inserted 6 hours ago and has abdominal distention
• D. A client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat

Correct answer: D

Rationale: The client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat should be assessed first. This client may be experiencing airway obstruction due to hematoma or swelling, making it a priority. Options A, B, and C have concerning findings as well, but airway compromise takes precedence over other issues.

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