Nursing Elites

1. What is a priority goal of involuntary hospitalization of the severely mentally ill client?

• A. Re-orientation to reality
• B. Elimination of symptoms
• C. Protection from harm to self or others
• D. Return to independent functioning

Correct answer: C

Rationale: The priority goal of involuntary hospitalization of severely mentally ill clients is to ensure protection from harm to self or others. Involuntary hospitalization is often necessary for individuals who are deemed dangerous to themselves or others or who are considered gravely disabled. Re-orientation to reality, elimination of symptoms, and return to independent functioning are important aspects of mental health care but are not the primary goals of involuntary hospitalization. The main focus during involuntary hospitalization is to address safety concerns and prevent harm.

2. Which of the following outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

• A. The client will verbalize community resources from which to seek shelter after discharge.
• B. The client will write a plan to keep herself and her children safe.
• C. The client will contact an attorney for help with pressing charges.
• D. The client will be safe and receive treatment for injuries.

Correct answer: D

Rationale: During the crisis stage of caring for a victim of domestic violence, the immediate priority is ensuring the client's safety and providing treatment for any injuries sustained. This focuses on addressing the urgent physical and emotional needs of the victim. While options like verbalizing community resources or creating safety plans are important for long-term support, they are not the primary concerns during the crisis phase. Contacting an attorney for legal assistance, though vital in the future, is not the immediate priority during the crisis stage when the client's safety and health are at the forefront.

3. Which action should the nurse implement when providing wound care instructions to a client who does not speak English?

• A. Ask an interpreter to provide wound care instructions.
• B. Speak directly to the client, with an interpreter translating.
• C. Request the accompanying family member to translate.
• D. Instruct a bilingual employee to read the instructions.

Correct answer: B

Rationale: When providing wound care instructions to a client who does not speak English, the nurse should speak directly to the client with the assistance of an interpreter for accurate translation. The interpreter is trained to provide objective translations in the client's primary language, ensuring the client understands the instructions and can ask questions. Using family members for translation is discouraged as they may alter instructions or feel uncomfortable discussing certain topics. Instructing a bilingual employee to read the instructions is not ideal as they may lack the necessary training in accurate interpretation, which could lead to misunderstandings in crucial wound care instructions.

4. Why is it important for the nurse to inform the family about the client's situation?

• A. To decrease the client's anxiety
• B. To help the family better adapt to necessary role changes
• C. To improve communication between family and nursing staff
• D. To ensure a more relaxed atmosphere for the client

Correct answer: B

Rationale: It is crucial for the nurse to inform the family about the client's situation to help them better adapt to necessary role changes. By providing early notification, the family can start preparing for potential adjustments. While reducing the client's anxiety and improving communication with the nursing staff are important, the primary purpose is to assist the family in undertaking the required role changes. Creating a relaxed atmosphere for the client, although beneficial, is not the main objective in this situation.

5. Which statement by an 8-year-old girl, who was just admitted to the hospital, needs to be explored?

• A. ''Wow! This hospital has bright colors.''
• B. ''Is my mother allowed to visit me tonight?'
• C. ''Those boys are so cute. I hope their room is next to mine!'
• D. ''I'm scared about being here. Can you stay with me awhile?'

Correct answer: C

Rationale: The correct answer is C. An 8-year-old child showing a strong attraction to boys at this age may raise concerns about precocious sexual behavior or exposure to inappropriate sexual content, potentially signaling the need to investigate for possible sexual abuse. It is important to explore this statement further. Choice A, expressing admiration for bright colors, is a common behavior for children of this age and does not raise immediate concerns. Choice B, inquiring about the mother's visit, is a typical concern for a hospitalized child seeking comfort and support. Choice D, expressing fear and seeking reassurance from the nurse, is also a normal reaction for an 8-year-old in a new and possibly intimidating environment. However, the statement in Choice C stands out as it deviates from age-appropriate behavior and warrants further exploration to ensure the child's safety and well-being.

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