Nursing Elites

1. During a discussion about glaucoma at the community center, which comment by one of the retirees would the nurse give a supportive comment to reinforce correct information?

• A. ''I usually avoid driving at night since lights sometimes seem to make things blur.''
• B. ''I take half of the usual dose for my sinuses to maintain my blood pressure.''
• C. ''I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.''
• D. ''I take extra fiber and drink lots of water to avoid getting constipated.''

Correct answer: D

Rationale: The correct answer is ''I take extra fiber and drink lots of water to avoid getting constipated.'' In individuals with glaucoma, activities that involve straining, such as constipation, should be avoided as they can increase intraocular pressure. Choices A, B, and C are incorrect as they do not align with the management of glaucoma. Driving at night or taking sinus medication are not directly related to glaucoma, and sitting by the pool due to an eye problem does not provide information relevant to managing glaucoma.

2. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

• A. Ask whether the voices are male or female and how many there are.
• B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
• C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
• D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

3. While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.

4. At a senior citizens meeting, a healthcare professional talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?

• A. ''I give myself insulin injections in my thighs.''
• B. ''Sometimes when I put my shoes on, I don't know where my toes are.''
• C. ''Here are my glucose readings that I noted on my calendar.''
• D. ''If I bathe more than once a week, my skin feels too dry.''

Correct answer: B

Rationale: The correct answer is when the client states, ''Sometimes when I put my shoes on, I don't know where my toes are.'' This statement indicates peripheral neuropathy, which can lead to a lack of sensation in the lower extremities. When clients are unable to feel pressure or pain in their feet, they are at a high risk for skin impairment, such as cuts, wounds, or ulcers. Option A is not directly related to impaired skin integrity, as self-administering insulin in the thighs does not pose a direct risk to skin integrity. Option C shows good glucose monitoring, which is important but does not directly indicate impaired skin integrity. Option D suggests dry skin due to infrequent bathing, which is more related to general skin care and not as predictive of impaired skin integrity as the statement in Option B.

5. Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?

• A. Asking to speak to someone
• B. Asking to be alone
• C. Listening to music
• D. All of the above

Correct answer: D

Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.

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