Nursing Elites

1. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

2. A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

• A. Ask, 'Tell me what I can do to help you overcome your fear of giving yourself injections.'
• B. Instruct, 'You need to learn how to give yourself insulin injections immediately.'
• C. State, 'Insulin injections are important for managing your diabetes, so you must learn them.'
• D. Mention, 'Many people with diabetes manage well with insulin injections.'

Correct answer: A

Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.

3. A group member is being taught about expected changes of aging by a nurse. Which statement by the group member shows effective learning?

• A. ''I should expect my heart rate to take longer to return to normal after excessive exercise as I get older.''
• B. ''I should expect my vision to improve as I age.''
• C. ''I should expect my skin to become more elastic as I age.''
• D. ''I should expect my hearing to become more acute as I age.''

Correct answer: A

Rationale: Choice A is the correct answer because as individuals age, there is a normal decline in cardiac efficiency, leading to a slower return to baseline heart rate after exercise. This statement demonstrates an understanding of an expected change related to aging. Choice B is incorrect as vision typically declines with age due to changes in the eye's structure. Choice C is incorrect because aging usually leads to a decrease in skin elasticity. Choice D is incorrect as hearing tends to decline rather than become more acute with age.

4. During a client admission, how should the nurse conduct medication reconciliation?

• A. Compare the client’s home medications to the provider's prescriptions.
• B. Review the client’s medical history.
• C. Assess the client's current medications.
• D. Ask the client about their allergies.

Correct answer: A

Rationale: During medication reconciliation, the nurse should compare the client’s home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client’s medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.

5. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

• A. Assume a decision-making role
• B. Seek input from staff
• C. Use a non-directive approach
• D. Shared decision-making with others

Correct answer: A

Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.

Similar Questions