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 updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?

• A. Have the client lie down after meals
• B. Encourage the client to speak while eating
• C. Have the client sit upright for 1 hour following meals
• D. Offer thin liquids with meals

Correct answer: C

Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour following meals. This position facilitates swallowing and reduces the risk of aspiration. Choice A is incorrect because having the client lie down after meals can increase the risk of aspiration. Choice B is incorrect as talking while eating can lead to choking. Choice D is incorrect as thin liquids may be harder for a client with dysphagia to swallow safely.

3. A nurse is caring for a client who is 38 weeks pregnant and has a history of herpes simplex virus 2. Which question is most appropriate for the nurse to ask?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask is whether the client has any active herpes lesions. This is crucial because the presence of active lesions can necessitate a cesarean section to prevent transmission of the virus to the newborn. Asking about membrane rupture (choice A) is important but not directly related to the client's herpes simplex virus 2 status. Inquiring about the frequency of contractions (choice B) is relevant for assessing labor progression but does not address the immediate concern of herpes transmission. Asking about being positive for beta strep (choice D) is important for determining the need for prophylactic antibiotics during labor, but it is not directly related to the client's herpes simplex virus 2 status.

4. A provider has written a do not resuscitate (DNR) order for a client who is comatose and does not have advance directives. A member of the client’s family says, 'I wonder when the doctor will tell us what’s going on.' Which of the following actions should the nurse take first?

• A. Request that the provider provide more information to the family.
• B. Refer the family to a support group for grief counseling.
• C. Offer to answer questions that family members have.
• D. Ask the family what the provider has discussed with them.

Correct answer: D

Rationale: The correct action for the nurse to take first is to ask the family what the provider has discussed with them. This allows the nurse to clarify any misunderstandings and ensures that the family is fully informed before providing further information. Option A is not the best choice because it assumes the need for more information without first understanding what has already been communicated. Option B is premature as the family may not be ready for grief counseling at this stage. Option C, although a good general practice, is not the most appropriate immediate action in this situation where clarifying existing information is crucial.

5. A home health nurse is carefully planning care for a client with Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is essential for clients with Alzheimer's disease as it helps in orienting them to time and day, providing structure, and minimizing confusion in their daily routine. This action supports cognitive function and independence. Choice B is incorrect as it does not directly address cognitive orientation. Choice C is not a priority in the care plan and may not significantly impact the client's daily functioning. Choice D, creating variation in the daily routine, can actually increase confusion and anxiety in clients with Alzheimer's disease who thrive on predictability and structure.

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