Nursing Elites

1. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?

• A. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it
• B. Telling the nursing student to allow the client to rest
• C. Telling the client that the refusal of care will be informed to the health care provider
• D. Telling the nursing student to give the client the bath anyway

Correct answer: B

Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.

2. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

• A. "I should raise him to a sitting position."?
• B. "I should check for a fecal impaction."?
• C. "I should look for a kink in the urinary catheter tubing."?
• D. "I should observe whether symptoms worsen."?

Correct answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

3. The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, "Will you promise me you will be my nurse tomorrow?"? Which response is most appropriate?

• A. "Yes, I promise you I will be your nurse during my shift tomorrow."?
• B. "You will need to speak to my supervisor about this request."?
• C. "While I cannot promise that I will be your nurse tomorrow, I can talk to the charge nurse about this request."?
• D. "Because of confidentiality, I cannot discuss tomorrow's assignments with you."?

Correct answer: D

Rationale: The most appropriate response is to maintain confidentiality regarding work assignments. It is crucial to uphold patient privacy and not disclose information about staff schedules or assignments. Choices A, B, and C involve promising or redirecting the patient, which is not suitable in this situation. Choice D respects confidentiality and is the most professional response in this scenario.

4. A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?

• A. Physical therapy
• B. Occupational therapy
• C. Home care
• D. Social services

Correct answer: B

Rationale: An occupational therapist assists clients with impairments in performing activities of daily living, such as feeding themselves with the use of adaptive devices. In this case, the client needs help with holding utensils while eating, falling under the scope of occupational therapy. Home care provides general support services but doesn't specifically address the client's need for utensil use. Social services focus on counseling and financial aspects of care, not physical rehabilitation like occupational therapy does. Physical therapy primarily deals with physical disabilities through exercises, which is not the primary concern for the client's difficulty in holding utensils.

5. To remove hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
• B. Grasp the lens with a gentle pinching motion
• C. Don sterile gloves before attempting the procedure
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

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