Nursing Elites

1. A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic self-expectations) is when the client can:

• A. report a positive self-concept.
• B. identify negative thoughts.
• C. recognize positive thoughts.
• D. give one positive cue with each negative cue

Correct answer: A

Rationale: The correct answer is to 'report a positive self-concept.' The problem statement is Negative Self-Concept, so the goal is for the client to achieve a positive self-concept. This involves helping the client recognize their worth and strengths. Choices B, C, and D do not directly address the resolution of Negative Self-Concept. Identifying negative thoughts (B) is a step towards improvement but does not represent a successful resolution. Recognizing positive thoughts (C) is positive but not the primary goal in addressing Negative Self-Concept. 'Give one positive cue with each negative cue' (D) is not as comprehensive as achieving an overall positive self-concept.

2. A client reports hearing voices. What should the nurse do next?

• A. Touch the client to help him return to reality.
• B. Leave the client alone until reality returns.
• C. Ask the client to describe what is happening.
• D. Tell the client there are no voices.

Correct answer: C

Rationale: When a client reports hearing voices, it might indicate hallucinations. It is essential for the nurse to ask the client to describe what is happening to gain a better understanding of the hallucinations. This approach helps in assessing the severity and content of the hallucinations, which can guide further interventions. Touching the client without consent can be intrusive and may escalate the situation, violating the client's personal space. Leaving the client alone may not address the underlying issue of hallucinations and can lead to potential risks if the client is distressed. Telling the client there are no voices denies their experience, invalidates their feelings, and can result in mistrust between the client and the nurse.

3. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?

• A. Discard the solution and order a new bag
• B. Warm the solution
• C. Continue the infusion and document the finding
• D. Discontinue the medication

Correct answer: A

Rationale: Crystals in the solution are not normal and should not be administered to the client. Discarding the solution and ordering a new bag is the correct action to ensure the client's safety. Warming the solution, as suggested in answer B, will not resolve the issue of crystals and cloudiness, which could potentially harm the client. Continuing the infusion, as in answer C, could pose a risk to the client due to the presence of abnormal substances. Answer D, discontinuing the medication, would typically require a doctor's order and should be done after discarding the contaminated solution.

4. A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:

• A. "The amount of alcohol that is safe during pregnancy is unknown."?
• B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
• C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
• D. "You can have a drink to help you relax and get to sleep at night."?

Correct answer: A

Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? It is crucial for pregnant women to avoid alcohol as there is no known safe amount during pregnancy. Consuming any amount of alcohol can harm the developing fetus and increase the risk of fetal alcohol syndrome, a condition characterized by mental and physical abnormalities in infants. Choices B, C, and D are incorrect because they provide misleading information that can potentially harm the fetus. Pregnant women should abstain from alcohol to ensure the health and well-being of their baby.

5. A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:

• A. naloxone (Narcan)
• B. labetalol (Normodyne)
• C. neostigmine (Prostigmin)
• D. thiothixene (Navane)

Correct answer: A

Rationale: The correct answer is naloxone (Narcan). Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression and somnolence. In this scenario, the client's extreme somnolence and respiratory depression suggest an opioid overdose, making naloxone the appropriate choice to counteract these effects. Labetalol (Normodyne) is a nonselective beta-blocker used to treat hypertension, not opioid overdose. Neostigmine (Prostigmin) is a cholinesterase inhibitor used to reverse neuromuscular blockade, not opioid-induced respiratory depression. Thiothixene (Navane) is an antipsychotic medication used to treat schizophrenia and is not indicated for opioid overdose.

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