Nursing Elites

1. The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?

• A. The client is going through a grieving period.
• B. The client talks as if another person is affected.
• C. The client is willing to learn techniques to adapt.
• D. The client recognizes the reality and becomes anxious.

Correct answer: D

Rationale: In this scenario, the client's recognition of the reality and subsequent anxiety cues the nurse that the client is in the withdrawal phase of adjusting to the change in body image. During this phase, the client may refuse to discuss the change and may use withdrawal as a coping mechanism. The grieving period typically occurs during the acknowledgement phase, where the client and family come to terms with the change in physical appearance. Initially, shock and depersonalization may lead the client to talk as if another person is affected by the change. Finally, in the rehabilitation stage, the client is ready to learn techniques to adapt to the change, such as through the use of prosthetics or modifying lifestyles and goals.

2. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

• A. Provide the client with a list of reliable internet sites that offer information on medications.
• B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
• C. Reassure the client that information about the medication is included in the written instructions.
• D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.

Correct answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.

3. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the healthcare provider as soon as possible?

• A. Daily black, sticky stool
• B. Daily dark brown stool
• C. Firm brown stool every other day
• D. Soft light brown stool twice a day

Correct answer: A

Rationale: The correct answer is 'Daily black, sticky stool.' Black sticky stool (melena) is indicative of gastrointestinal bleeding, a serious condition that requires immediate attention from the healthcare provider. Options B and D, 'Daily dark brown stool' and 'Soft light brown stool twice a day,' respectively, represent variations of normal stool characteristics and do not raise immediate concerns about the client's health. Option C, 'Firm brown stool every other day,' suggests constipation, which is of lesser concern and can be managed with interventions.

4. A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?

• A. Ask him to rate his pain on a scale of 1 to 10.
• B. Encourage him to wait until bedtime so the pill can help him sleep.
• C. Attend to the acutely ill client's needs first because this client is laughing.
• D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.

5. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next?

• A. Witness the client's signature on the permit.
• B. Answer the client's questions about the surgery.
• C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
• D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to inform the surgeon that the operative permit is not signed and that the client has questions about the surgery. It is the responsibility of the surgeon to explain the procedure to the client and obtain the client's signature on the permit. While the nurse can witness the client's signature on the permit, the procedure must first be explained by the healthcare provider or surgeon, including addressing the client's questions. Therefore, informing the surgeon is the priority to ensure proper communication and consent before the surgery. Answering the client's questions about the surgery (Choice B) may not provide accurate information and could lead to misunderstanding. Reassuring the client (Choice D) is important, but obtaining proper consent and addressing concerns should come first. Witnessing the client's signature (Choice A) is not sufficient if the client has unanswered questions and the permit is not signed.

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