Nursing Elites

1. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?

• A. Allowing the client to function independently will strengthen muscles and promote healing.
• B. The client needs privacy at times for self-reflection and organizing life.
• C. The client’s sense of loss can be lessened through retaining control of some areas of life.
• D. Performing ADLs is a requirement prior to discharge from an acute care facility.

Correct answer: C

Rationale: The correct answer is C. In situations like terminal illness, allowing clients to perform activities of daily living (ADLs) can help maintain their sense of control and dignity, providing comfort and a sense of normalcy amidst their health challenges. Choice A is incorrect because in a terminal stage, the focus is not on muscle strength or promoting physical healing but rather on enhancing the client's emotional well-being. Choice B, while highlighting the importance of privacy, is not directly addressing the client's need for control and autonomy. Choice D is incorrect as the priority in this scenario is not related to discharge requirements but rather the client's emotional and psychological needs during their terminal illness.

2. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

3. A nurse is evaluating a client’s use of a cane. What is the correct use?

• A. Client holds the cane on the stronger side of the body.
• B. Client holds the cane on the weaker side of the body.
• C. Client holds the cane in front of the weaker side of the body.
• D. Client holds the cane in front of the stronger side of the body.

Correct answer: A

Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.

4. The healthcare provider is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the healthcare provider recommend?

• A. High protein, high calorie
• B. High carbohydrate, low fat
• C. High vitamin A, high vitamin E
• D. Fluid restricted, bland

Correct answer: A

Rationale: The correct answer is A: High protein, high calorie. An immobilized patient with impaired skin integrity requires a diet high in protein and calories to repair injured tissue and rebuild depleted protein stores. This helps in promoting wound healing and preventing further breakdown of the skin. Choices B, C, and D are incorrect because while vitamins and minerals are essential for overall health, in this case, the priority is on providing sufficient protein and calories to support healing and recovery in an immobilized patient with impaired skin integrity.

5. While caring for a client who is postoperative and has refused to use an incentive spirometer following major abdominal surgery, what is the nurse's priority action?

• A. Request that a respiratory therapist discuss the technique for using the incentive spirometer
• B. Determine the reasons why the client is refusing to use the incentive spirometer
• C. Document the client's refusal to participate in health restorative activities
• D. Administer a pain medication to the client

Correct answer: B

Rationale: The nurse's priority is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them appropriately. Requesting a respiratory therapist (Choice A) may be necessary later but is not the priority. Documenting the refusal (Choice C) is important but does not address the immediate need to assess and intervene. Administering pain medication (Choice D) without addressing the root cause of refusal is not appropriate and may mask the issue rather than resolve it.

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