Nursing Elites

1. The best way for a healthcare provider and a healthcare facility to control the effects of poor and disruptive patient behavior is to _________________.

• A. prevent it
• B. restrain the patient
• C. medicate the patient
• D. isolate the patient

Correct answer: A

Rationale: The most effective approach to managing poor and disruptive patient behavior is by preventing it proactively. This involves implementing strategies, communication techniques, and environmental modifications that address the underlying causes of the behavior. Restraint, medication, and isolation should only be used as a last resort when the patient or others are at risk of harm. Restraint and isolation are primarily used to ensure safety, while medication, especially when used solely to control behavior, can have adverse effects and is considered a measure of last resort. Therefore, prevention is crucial in promoting a therapeutic environment and fostering positive patient outcomes.

2. When a man with dementia is admitted to a long-term care facility, his wife, who appears tired and angry, says in a sarcastic tone, 'Let's see what you can do with him.' Which response is therapeutic?

• A. It sounds like it's been difficult for you.'
• B. I don't understand what you mean.'
• C. 'I have experience with all types of clients.'
• D. It's too bad you didn't admit him sooner.'

Correct answer: A

Rationale: The correct response is to acknowledge the caregiver's feelings and challenges without blaming them. Option A, 'It sounds like it's been difficult for you,' shows empathy and opens the channel of communication. Options B and C, 'I don't understand what you mean' and 'I have experience with all types of clients,' are nurse-focused responses that block effective communication. Option D, 'It's too bad you didn't admit him sooner,' is a hostile response that shifts the blame to the caregiver, which is not therapeutic in this situation.

3. A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?

• A. I'm sorry to hear that.'
• B. 'Oh, you have a lot of good years left.'
• C. 'You are concerned about your sex life?'
• D. 'Have you asked your primary health care provider about that?'

Correct answer: C

Rationale: The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I'm sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.

4. A client is being treated for anxiety and desires to be free from anxious feelings and despair. According to Maslow's hierarchy of needs, which level does this client need to meet?

• A. Physiological
• B. Safety
• C. Belonging
• D. Self-esteem

Correct answer: B

Rationale: According to Maslow's hierarchy of needs, safety needs come right after physiological needs. Safety needs include feelings of security and stability. When a client is treated for anxiety and seeks to be free from anxious feelings and despair, they are primarily aiming to meet their safety needs. By addressing anxiety and moving towards a sense of safety, the client can progress to addressing higher-level needs. Choices A, C, and D are incorrect in this scenario. Physiological needs (Choice A) refer to basic needs like food, water, and shelter. Belonging (Choice C) and self-esteem (Choice D) are higher-level needs in Maslow's hierarchy that come after safety needs. Therefore, the most appropriate level for the client in this case is safety.

5. The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?

• A. Place the client in a high Fowler position.
• B. Assist the client in assuming a left side-lying position.
• C. Measure the tube from the tip of the nose to the xiphoid process.
• D. Assist the client in flexing the neck forward to facilitate tube insertion.

Correct answer: A

Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.

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