Nursing Elites

1. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

• A. Review the client's weight pattern over the year
• B. Ask the mother to record her diet for the last 24 hours
• C. Encourage her to talk about her view of herself
• D. Give her several pamphlets on postpartum nutrition

Correct answer: C

Rationale: Encouraging the adolescent client to talk about her view of herself is the first action the nurse should take. Body image is crucial for adolescents, especially after pregnancy. By addressing the client's concerns about her weight and discussing her self-perception, the nurse can provide emotional support and open a dialogue for further assessment and teaching. Choice A, 'Review the client's weight pattern over the year,' is not the priority at this time as the client's immediate concern is her post-pregnancy weight. Choice B, 'Ask the mother to record her diet for the last 24 hours,' focuses on dietary habits rather than addressing the client's emotional concerns. Choice D, 'Give her several pamphlets on postpartum nutrition,' may be helpful but should come after addressing the client's emotional needs and concerns.

2. A female nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the nurse to intervene if she takes which action?

• A. The nurse explains the 0 to 10 intensity pain scale.
• B. The nurse asks the patient when the headaches started.
• C. The nurse sits down at the bedside and closes the privacy curtain.
• D. The nurse calls for a male nurse to bring a hospital gown to the room.

Correct answer: C

Rationale: In some Arab cultures, it is not considered appropriate for a male to be alone with a female who is not his spouse. Therefore, it is important for the nurse to respect the patient's cultural beliefs and privacy by ensuring that a female nurse is not alone with the male patient. Sitting down at the bedside and closing the privacy curtain could potentially lead to a situation where the nurse is alone with the patient, which goes against the patient's cultural norms. The other actions, such as explaining the pain scale, asking about the onset of headaches, and requesting a male nurse to bring a hospital gown, are all appropriate and do not conflict with the patient's cultural beliefs.

3. Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?

• A. A client follows the therapist's finger with their eyes while focusing on a negative thought or memory
• B. A client reads a story about a traumatic event and then visualizes the result
• C. A client focuses on a negative thought in their mind while tapping their fingers
• D. None of the above

Correct answer: A

Rationale: Eye Movement Desensitization and Reprocessing (EMDR) is a therapeutic approach used to address negative thoughts or traumatic memories, particularly in individuals with post-traumatic stress disorder. During EMDR, the client concentrates on a distressing thought or memory and the associated emotions while engaging in bilateral stimulation, often by moving their eyes back and forth. This bilateral stimulation can involve tracking the therapist's finger or other forms of sensory stimulation. Choice A is correct as it accurately describes the core process of EMDR. Choices B and C are incorrect as they do not involve the essential components of EMDR, which include eye movements or bilateral stimulation. Choice D is incorrect as EMDR is a specific therapeutic technique and not covered by selecting 'None of the above'.

4. A woman who had a mastectomy is scheduled for a mastectomy peer support visit arranged by her primary health care provider. What is the purpose of the referral?

• A. To teach arm exercises
• B. To prevent social isolation
• C. To meet her physical needs
• D. To view her surgical incision

Correct answer: B

Rationale: The purpose of a mastectomy peer support visit is to prevent social isolation. This visit helps the client maintain her social connections and learn about community resources. Teaching arm exercises and meeting physical needs are tasks for healthcare professionals, not the primary goal of a peer support visit. Viewing the surgical incision is also not the primary purpose of such a visit.

5. A client admitted with a diagnosis of cervical cancer tells the nurse, 'I haven't had a Papanicolaou (Pap) smear for more than 8 years. I probably wouldn't be in the hospital today if I'd had those tests more often.' Which response would the nurse provide?

• A. ''Please tell me why you waited so long.''
• B. 'You feel as though you've neglected your health.''
• C. 'It's never too late to start taking care of yourself.''
• D. 'Most women hate to have Pap smears done, but they're really important.''

Correct answer: B

Rationale: The correct response, ''You feel as though you've neglected your health,'' is appropriate as it indicates recognition of expressed feelings, encouraging verbalization. This response is nondirective and reflective. Choice A, asking the client why she waited so long, ignores the client's current emotional needs and may cut off communication. Choice C, stating that it is never too late to start taking care of her health, is judgmental as it implies that the client has been negligent. Choice D, although acknowledging the importance of Pap smears, fails to address the client's current emotional state and needs.

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