Nursing Elites

1. Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?

• A. Confront the delusional material directly by telling Gio that this simply is not so.
• B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
• C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
• D. Isolate Gio when he begins to talk about these beliefs.

Correct answer: B

Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.

2. The priority goal for a family who practices Chinese medicine would be to:

• A. Achieve harmony
• B. Maintain a balance of energy
• C. Respect life
• D. Restore yin and yang

Correct answer: D

Rationale: In Chinese medicine, the concept of yin and yang represents the balance of opposing forces in the body. When there is an imbalance between yin and yang, it can result in illness. Therefore, the priority goal for a family practicing Chinese medicine would be to restore the harmony and balance between yin and yang. Choices A, B, and C are not the priority goal in Chinese medicine. While achieving harmony, maintaining a balance of energy, and respecting life are important aspects of Chinese medicine, the fundamental principle revolves around maintaining the equilibrium of yin and yang for optimal health.

3. When a mother is inquiring about her child's ability to potty train, what is the most critical aspect of toilet training?

• A. The age of the child
• B. The child's ability to understand instructions
• C. The overall mental and physical abilities of the child
• D. Consistent attempts with positive reinforcement

Correct answer: C

Rationale: The most critical aspect of toilet training is the overall mental and physical abilities of the child. While age can play a role, it is not the sole determining factor. Understanding instructions is important but may not be the most critical aspect. Consistent attempts with positive reinforcement can be helpful, but without considering the child's abilities, it may not lead to successful potty training.

4. Which of the following interventions should be prioritized in the care of the suicidal client?

• A. Remove all potentially harmful items from the client's room
• B. Allow the client to express feelings of hopelessness
• C. Note the client's capabilities to increase self esteem
• D. Set a "no suicide"? contract with the client

Correct answer: A

Rationale: accessibility of the means of suicide increases the lethality. Allowing a patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients but not specifically for suicide.

5. Plantar flexion can be prevented with ________________.

• A. foot soaks
• B. foot boards
• C. toenail care
• D. proper shoes

Correct answer: B

Rationale: Plantar flexion, or foot drop, can be prevented with foot boards, special splints, and range of motion exercises. Foot boards help maintain the foot in a neutral position, preventing contractures and deformities. Foot soaks (choice A) may help with foot hygiene but do not directly prevent plantar flexion. Toenail care (choice C) is important for overall foot health but does not prevent plantar flexion. Proper shoes (choice D) are essential for foot support and comfort but do not specifically prevent plantar flexion.

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