Nursing Elites

1. A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?

• A. Confront the client about this behavior.
• B. Express sympathy for the client's situation.
• C. Speak assertively to the client.
• D. Stand within 30 cm (1 ft) of the client when speaking with them.

Correct answer: A

Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.

2. Which of the following actions should be taken to use a wide base support when assisting a client to get up in a chair?

• A. Bend at the waist and place arms under the client’s arms and lift
• B. Face the client, bend knees, and place hands on the client’s forearm and lift
• C. Spread the feet apart
• D. Tighten the pelvic muscles

Correct answer: C

Rationale: The correct answer is C: Spread the feet apart. When assisting a client to get up in a chair, it is crucial to use a wide base of support to maintain stability and prevent injuries. Spreading the feet apart provides a broader base, increasing balance and support for both the client and the caregiver. This position helps distribute the weight evenly and allows for better control when assisting the client in moving. Choices A, B, and D are incorrect because bending at the waist, placing arms under the client's arms, tightening pelvic muscles, or placing hands on the client's forearm do not provide the necessary wide base support needed for stability and safety during the transfer process.

3. Which of the following clusters of data belong to Maslow’s hierarchy of needs?

• A. Love and belonging
• B. Physiological needs
• C. Self-actualization
• D. All of the above

Correct answer: D

Rationale: Maslow's hierarchy of needs is a theory in psychology that categorizes human needs into five levels: physiological needs, safety needs, love and belongingness, esteem needs, and self-actualization. 'Love and belonging' corresponds to the third level, 'Physiological needs' to the first level, and 'Self-actualization' to the highest level. Therefore, all the clusters listed in the choices are part of Maslow's hierarchy of needs. Selecting 'All of the above' (option D) is the correct answer as it includes all the clusters associated with Maslow's theory.

4. What is another name for the knee-chest position?

• A. Genu-dorsal
• B. Genu-pectoral
• C. Lithotomy
• D. Sim’s

Correct answer: B

Rationale: The knee-chest position is correctly identified as the genu-pectoral position. In this position, a person rests on their knees and chest with the abdomen raised and the head turned to one side. This position is commonly used in medical examinations and procedures involving the rectal or pelvic areas, allowing for better visualization and access. Choice A, 'Genu-dorsal,' is incorrect as it does not refer to the knee-chest position. Choice C, 'Lithotomy,' is incorrect as it refers to a position where the patient is lying on their back with legs flexed and feet in stirrups, commonly used during childbirth or certain surgeries. Choice D, 'Sim’s,' is incorrect as it refers to a position where the patient lies on their left side with the right knee and thigh drawn up with the left arm placed along the back.

5. What do high-pitched gurgles heard over the right lower quadrant indicate?

• A. Increased bowel motility
• B. Decreased bowel motility
• C. Normal bowel sounds
• D. Abdominal cramping

Correct answer: C

Rationale: High-pitched gurgles heard over the right lower quadrant indicate normal bowel sounds. Bowel sounds can vary in pitch, and high-pitched gurgles are considered normal and indicate the presence of active peristalsis in the intestines.

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