Nursing Elites

1. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to

• A. Give the client orientation materials and review the unit rules and regulations
• B. Introduce oneself and accompany the client to their room
• C. Take the client to the day room and introduce them to the other clients
• D. Ask the nursing assistant to get the client’s vital signs and complete the admission search

Correct answer: B

Rationale: In situations where a client is trembling and fearful upon admission to a psychiatric unit, it is essential to prioritize building trust and reducing anxiety. By introducing oneself and accompanying the client to their room, the nurse can establish a therapeutic relationship, provide a sense of security, and address the client's immediate emotional needs. Choices A, C, and D are not the most appropriate initial responses as they do not directly address the client's emotional state or focus on establishing a supportive relationship.

2. A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of which task?

• A. Loss of control
• B. Insecurity
• C. Dependence
• D. Lack of trust

Correct answer: C

Rationale: A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of the task of dependence. Prolonged illness and confinement can lead to the development of dependence as the individual may become reliant on others for their care and needs. Choices A, B, and D are incorrect in this context. Loss of control, insecurity, and lack of trust are important factors to consider but are not directly related to the altered growth and development task of dependence due to illness and confinement.

3. As a community health nurse covering a cluster of Barangays, your population coverage includes the following:

• A. Families in their homes, School population, Workers in factories
• B. Families in their homes, School population, Patients in hospital
• C. All except workers in factories
• D. All except patients in hospital

Correct answer: A

Rationale: The correct answer is A: 'Families in their homes, School population, Workers in factories.' As a community health nurse, you are responsible for providing healthcare services and promoting health within the community. This includes visiting families in their homes to assess their health needs, working with the school population to educate them on preventive health measures, and ensuring the health and safety of workers in factories. Choices B, C, and D are incorrect because they do not encompass the full scope of a community health nurse's responsibilities. Choice B does not include workers in factories, Choice C excludes an important population group, and Choice D excludes an essential setting where healthcare services are provided.

4. The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?

• A. Infant will experience minimal pain
• B. Muscle spasms will be relieved
• C. Mobility will be managed as tolerated
• D. Tissue perfusion will be maintained

Correct answer: D

Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.

5. The emphasis of community health nursing is on:

• A. treatment of health problems
• B. preventing problems and promoting optimum health
• C. identification and assessment of health problems
• D. illness end of the wellness-illness continuum

Correct answer: B

Rationale: Community health nursing primarily focuses on preventive measures and promoting overall health within a community. Choice A is incorrect as treatment is not the main emphasis. Choice C is incorrect as identification and assessment are steps that may be involved but not the main focus. Choice D is incorrect as it refers to the illness end rather than the preventive end of the wellness-illness continuum.

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