Nursing Elites

1. A twenty-one-year-old man suffered a concussion, and the MD ordered an MRI. The patient asks, 'Will they allow me to sit up during the MRI?' The correct response by the nurse should be:

• A. "I will have to talk to the doctor about letting you sit upright during the test."?
• B. "You will be positioned in the reverse Trendelenburg position to maximize the view of the brain."?
• C. "The radiologist will let you know."?
• D. "You will have to lie down on your back during the test."?

Correct answer: D

Rationale: The correct answer is to inform the patient that they will have to lie down on their back during the MRI. This positioning is necessary for the scan to obtain accurate images of the brain. Choice A is incorrect because the decision on the positioning during the MRI is typically determined by the imaging protocol and not subject to negotiation during the test. Choice B is incorrect as the reverse Trendelenburg position is not commonly used during MRI scans. Choice C is incorrect because the radiologist does not usually make decisions on patient positioning during the MRI; it is predetermined by the imaging requirements.

2. As a type of quality indicator, an example of a structure standard is:

• A. a written philosophy.
• B. a procedure for a straight catheterization.
• C. a protocol for treatment of a client with chest pain.
• D. the diagnostic work-up for a client with abdominal pain.

Correct answer: A

Rationale: The correct answer is 'a written philosophy.' Structure standards define the conditions needed to operate a system and do not directly involve client care. Examples include philosophy, objectives, goals, hours of operation, and management responsibility. Choices B, C, and D involve specific procedures and protocols related to client care, which are not structure standards.

3. What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?

• A. Discussing the repetitive actions.
• B. Insisting the client not perform the repetitive act.
• C. Informing the client that the act is not necessary.
• D. Encouraging daily exercise.

Correct answer: D

Rationale: An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.

4. Which of the following coping mechanisms protects an individual from anxiety?

• A. denial and fantasy
• B. rationalization and suppression
• C. regression and displacement
• D. reaction formation and projection

Correct answer: A

Rationale: The correct answer is 'denial and fantasy.' Denial involves blocking external events from awareness to avoid anxiety, while fantasy is escaping to a more comfortable, less threatening place. These mechanisms can protect individuals from anxiety by providing temporary relief or distraction. Choices B, C, and D are incorrect. Rationalization and suppression do not directly protect individuals from anxiety. Regression and displacement involve reverting to earlier developmental stages or redirecting emotions to a substitute target, which do not directly shield individuals from anxiety. Reaction formation and projection entail behaving in the opposite way to one's impulses or attributing one's feelings to others respectively, which do not directly protect individuals from anxiety.

5. If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?

• A. Document the finding
• B. Send a specimen to the lab
• C. Strain the dialysate
• D. Obtain a complete blood count

Correct answer: B

Rationale: When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.

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