Nursing Elites

1. 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.

2. If you are caring for a patient of the Hindu culture, what may you anticipate regarding visitors?

• A. Limited visitors, respectful of privacy
• B. Family members only
• C. Large number of visitors/community support
• D. None of the above

Correct answer: C

Rationale: In Hindu culture, there is a strong sense of community and support. It is common for a patient to receive a large number of visitors, indicative of the community coming together to provide emotional and practical support. This support network is crucial for the patient's well-being and healing process. Option A, limited visitors, is incorrect as the Hindu culture values community involvement. Option B, family members only, is incorrect as the support network extends beyond just family. Option D, none of the above, is incorrect as the Hindu culture typically involves community support and a significant number of visitors.

3. A nurse is using active listening as a form of therapeutic communication when:

• A. She uses humor to put the client at ease in a situation
• B. She restates what the client said in slightly different words
• C. She uses eye contact and maintains an open stance while the client is talking
• D. She provides personal information to show the client she can relate to him

Correct answer: C

Rationale: Active listening is a form of therapeutic communication that involves the nurse encouraging a client to express their thoughts and feelings. Maintaining eye contact and an open stance while the client is talking demonstrates active listening and shows the client that they are being heard and understood. Using humor (Choice A) may not always be appropriate or therapeutic in all situations. Restating what the client said (Choice B) is a technique known as paraphrasing and is also a form of active listening. Providing personal information (Choice D) can shift the focus from the client to the nurse, which is not the intention of active listening.

4. A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

• A. Stop the interview at this point and resume later when the client is better able to concentrate
• B. Ask the client, 'Are you seeing something on the ceiling?'
• C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
• D. Continue the interview without commenting on the client's behavior

Correct answer: B

Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.

5. A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?

• A. Ask the client to undress to assess for injuries
• B. Take the client into a private room
• C. Notify the police to file a report
• D. Notify the house supervisor to keep security on alert

Correct answer: B

Rationale: When dealing with a client suspected of domestic violence, it is crucial to provide privacy and a safe environment. Taking the client into a private room allows for a confidential conversation and assessment without compromising the client's safety or dignity. The nurse should prioritize creating a safe space for the client to share information and receive support. Notification of authorities should only occur once a thorough assessment has been conducted to ensure the client's safety and well-being. Option A is incorrect because asking the client to undress should be done with sensitivity and respect for the client's privacy, focusing on assessing injuries rather than visualizing them. Option C is premature as involving the police should be based on a comprehensive assessment and the client's consent. Option D is not the most immediate and direct action required to address the client's immediate needs in a suspected domestic violence situation.

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