Nursing Elites

1. Identify the type of 'trigger' with the correct 'trigger' that can possibly lead to disturbed behavior.

• A. Emotional: room coldness
• B. Environmental: boredom
• C. Physical: pain
• D. Communication: silence

Correct answer: C

Rationale: Physical pain is a common trigger that can lead to disturbed behavior in individuals, especially when they are unable to communicate their pain effectively. Choices A, B, and D are incorrect. Room coldness falls under environmental triggers, boredom is associated with emotional triggers, and silence is a communication aspect rather than a direct trigger for disturbed behavior.

2. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention?

• A. The cuff wraps around the girth of the leg.
• B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
• C. The client is placed in a prone position.
• D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

Correct answer: B

Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse should be auscultated when the blood pressure cuff is applied around the thigh. The nurse should intervene when the UAP is auscultating the popliteal pulse with the cuff on the lower leg because this is incorrect placement. Option A, wrapping the cuff around the girth of the leg, ensures an accurate assessment. Option C, placing the client in a prone position, provides the best access to the artery. The systolic pressure in the popliteal artery is typically 10 to 40 mm Hg higher than in the brachial artery, so a systolic reading 20 mm Hg higher than the blood pressure in the client's arm is within the expected range and does not require intervention.

3. Which intervention should the nurse use for a client who hallucinates, yells, and curses throughout the day?

• A. Ignore the client's behavior if the client is not harming anyone.
• B. Isolate the client until the behavior decreases or stops.
• C. Explain how the behavior affects other people on the unit.
• D. Seek to understand what the behavior means to the client.

Correct answer: D

Rationale: When a client experiences hallucinations, yells, and curses, it is essential to seek to understand the underlying meaning of their behavior. All behavior has significance, and understanding the client's perspective can guide appropriate interventions. Ignoring the behavior may exacerbate the situation and isolating the client could lead to increased anxiety and further acting out. Explaining the impact on others is not helpful in this scenario as the client is not intentionally hallucinating; yelling and cursing are responses to the hallucinations.

4. The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to their daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine they are currently following.

Correct answer: D

Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.

5. When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?

• A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.

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