Nursing Elites

1. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

2. The PN is caring for an older client who was informed about the diagnosis of terminal cancer two days ago. Which intervention would be most helpful for the client's spouse at this time?

• A. Consultation with the case manager and hospital chaplain
• B. Visiting after procedures are done to avoid seeing the client in pain
• C. Participating in the client's care within his/her capabilities and desires
• D. Information about palliative and hospice care services

Correct answer: D

Rationale: Providing information about palliative and hospice care services can help the spouse understand the options for managing the client's symptoms and improving the quality of life. This also provides support and guidance during a difficult time. Consulting with the case manager and hospital chaplain may be beneficial for emotional support but may not address the practical aspects of care. Visiting after procedures are done to avoid seeing the client in pain may not foster open communication and support. While participating in the client's care is important, providing information about palliative and hospice care services is the most helpful intervention in this scenario.

3. Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?

• A. How much exercise did the child have today?
• B. Did the child perform a finger stick?
• C. When did the child last urinate?
• D. Has the child eaten recently?

Correct answer: B

Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.

4. For an older postoperative client with the nursing diagnosis 'impaired mobility related to fear of falling,' which desired outcome best directs the nurse's actions for the client?

• A. The client will ambulate with assistance every 4 hours
• B. The physical therapist will instruct the client in the use of a walker
• C. The client will use self-affirmation statements to decrease fear
• D. The nurse will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: Encouraging the client to use self-affirmation statements is the most appropriate desired outcome in this scenario. By utilizing self-affirmation statements, the client can address their fears directly and build confidence, which can ultimately lead to a reduction in fear of falling. While ambulating with assistance (choice A) is important, the focus here is on addressing the fear itself. Instructing the client in the use of a walker (choice B) and placing a gait belt on the client (choice D) are interventions that may be helpful but do not directly address the client's fear of falling.

5. The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?

• A. Ask her to share how the injury occurred to her child.
• B. Recommend that she remain calm and positive for her child.
• C. Express that the present situation must be overwhelming.
• D. Determine if someone else can help her cope with this tragedy.

Correct answer: C

Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.

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