Nursing Elites

1. An older woman has lived alone since the death of her husband 10 years ago, and she has a long list of vague complaints. Which assessment is the priority for the home health nurse to perform?

• A. Assess for feelings of loneliness and isolation.
• B. Determine if the client has unresolved grief.
• C. Determine if there are safety issues.
• D. Ask about the availability of support systems.

Correct answer: C

Rationale: The priority assessment for the home health nurse in this scenario is to determine if there are safety issues. The client is an older woman living alone with a long list of vague complaints, indicating several risk factors. Ensuring her safety should be the primary concern. While assessing for feelings of loneliness, isolation, or grief is important, ensuring the client's safety takes precedence due to her vulnerable situation. Although assessing the availability of support systems is essential in a home health assessment, safety issues must be addressed first given the client's profile.

2. The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?

• A. Use Liquid PaperTM to 'white out' the resolved diagnosis on the care plan
• B. Recopy the care plan without the resolved diagnosis
• C. Write a nursing progress note indicating that the outcome goals have been achieved
• D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

Correct answer: D

Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.

3. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?

• A. "I don't remember anything about what happened to me."
• B. "I'd rather not talk about it right now."
• C. "It's the other guy's fault! He was going too fast."
• D. "My mother is heartbroken about this."

Correct answer: A

Rationale: The correct answer is "I don't remember anything about what happened to me." This statement indicates the use of suppression, which is the willful act of putting an unacceptable thought or feeling out of one's mind. In this case, the client is deliberately excluding memories of the traumatic event to protect their self-esteem. The other choices do not reflect suppression: Choice B shows avoidance or deflection, Choice C demonstrates blame shifting, and Choice D indicates empathy towards another individual.

4. What is the similarity between the stage-crisis theory proposed by Havighurst and the psychosocial development theory formulated by Erikson?

• A. Based on developmental tasks
• B. Incorporate eight stages of development
• C. Based on changes in a person's thoughts and emotions
• D. Emphasize that a child's growth is directed by individual gene activity

Correct answer: A

Rationale: Both Havighurst's stage-crisis theory and Erikson's psychosocial development theory are grounded in the concept of developmental tasks. They both emphasize that successful completion of specific tasks at various life stages is crucial for healthy development. While Erikson's theory consists of eight stages of psychosocial development, Havighurst's theory comprises six stages. The idea that a child's growth is guided by individual gene activity is attributed to Gesell's theory, not Havighurst or Erikson. The emphasis on changes in a person's thoughts, emotions, and behaviors shaping beliefs about morality aligns with moral development theory, not specifically with Havighurst's or Erikson's theories.

5. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?

• A. Self-care deficit
• B. Functional incontinence
• C. Fluid volume deficit
• D. High risk for infection

Correct answer: D

Rationale: The correct answer is 'High risk for infection.' When caring for a client with an indwelling urinary catheter, the highest priority is to prevent infections, as these catheters are a significant source of infection. Options A and B, self-care deficit and functional incontinence, may be concerns but are not directly related to the indwelling catheter. Option C, fluid volume deficit, is not typically associated with the presence of an indwelling urinary catheter.

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