Nursing Elites

1. A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?

• A. prosecuting the perpetrator
• B. managing symptoms of anxiety and fear
• C. determining if the memories are real
• D. collaborating with the client's story

Correct answer: B

Rationale: The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.

2. What are appropriate nursing strategies to assist a client in maintaining a sense of self?

• A. Addressing the client by their first name when interacting with them
• B. Treating the client with dignity
• C. Explaining procedures to the client regardless of their attentiveness
• D. Encouraging the use of personal items to foster a sense of identity

Correct answer: B

Rationale: Maintaining a sense of self is crucial for clients in healthcare settings. Treating the client with dignity is a fundamental nursing principle that helps preserve the client's self-worth and identity. Addressing the client by their first name when interacting with them is a way to show respect, but it alone may not significantly contribute to maintaining their sense of self. Explaining procedures to the client, regardless of their attentiveness, is essential for informed consent and autonomy, empowering them in their care. Encouraging the use of personal items can foster a sense of identity as these items often hold personal significance and emotional value for the client, thus supporting their sense of self; therefore, discouraging their use would be counterproductive in maintaining a client's sense of self.

3. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

• A. Decreased appetite
• B. A low-grade fever
• C. Chest congestion
• D. Constant swallowing

Correct answer: D

Rationale: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade fever; thus, answers A and B are incorrect. Chest congestion, as mentioned in answer C, is not typical of tonsillectomy complications, making it an incorrect choice.

4. A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?

• A. Reinsert the protruding organ and cover with 4x4s
• B. Cover the wound with a sterile 4x4 and ABD dressing
• C. Cover the wound with a sterile saline-soaked dressing
• D. Apply an abdominal binder and manual pressure to the wound

Correct answer: B

Rationale: In the scenario where a client's wound eviscerates, the most appropriate nursing action is to cover the wound with a sterile saline-soaked dressing. Reinserting the protruding organ, as mentioned in choice A, is incorrect because it can lead to further complications requiring the client to return to surgery. Choice B, covering the wound with a sterile 4x4 and ABD dressing, is not ideal as it may not provide adequate protection and moisture for the exposed tissue. Choice D, applying an abdominal binder and manual pressure to the wound, is inappropriate as it does not address the specific needs of wound evisceration. Covering the wound with a sterile saline-soaked dressing helps maintain a moist environment, protects the exposed tissue, and prevents infection, promoting optimal wound healing and reducing the risk of complications.

5. Which information should be reported to the state Board of Nursing?

• A. The facility fails to provide literature in both Spanish and English.
• B. The narcotic count has been incorrect on the unit for the past 3 days.
• C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
• D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

Correct answer: B

Rationale: The correct answer is 'The narcotic count has been incorrect on the unit for the past 3 days.' This information should be reported to the state Board of Nursing as it involves medication errors and potential drug diversion, which are serious issues that fall under the jurisdiction of the Board. Reporting medication discrepancies and errors in narcotic counts is crucial for patient safety and regulatory compliance. Choices A, C, and D involve different types of issues that are not within the direct purview of the Board of Nursing. Providing literature in multiple languages (Choice A), addressing billing practices (Choice C), and resolving staff performance issues (Choice D) should be handled internally or reported to the appropriate departments or authorities, such as the Joint Commission or the charge nurse.

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