Nursing Elites

1. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:

• A. Grimacing and writhing movements decrease with relaxation and rest.
• B. Hypoactive deep tendon reflexes become more active with rest.
• C. Stretch reflexes are increased with rest.
• D. Fine motor movements are improved.

Correct answer: A

Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.

2. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: When addressing suspected abuse, it is crucial to ask direct questions to determine the cause of injuries. Choice B is the most appropriate as it directly inquires about the possibility of someone grabbing the client's arms, which could indicate abuse. This question can help uncover potential abuse and provide necessary intervention. Choices A, C, and D are less direct and may not elicit the critical information needed to address abuse effectively. Clients often hesitate to report abuse due to feelings of shame and fear of retaliation, making a direct approach essential in such situations.

3. The Token Economy is a type of therapy that focuses on:

• A. play therapy
• B. behavior modification
• C. milieu therapy
• D. associative

Correct answer: B

Rationale: The correct answer is 'behavior modification.' The Token Economy is a form of behavior modification that involves providing positive reinforcement in the form of tokens or rewards for desired behaviors. This approach aims to increase the occurrence of positive behaviors by rewarding them. Play therapy (choice A) focuses on using play as a medium for therapeutic communication, not specifically behavior modification. Milieu therapy (choice C) involves shaping the environment to promote desired behaviors but is not the primary focus of the Token Economy. 'Associative' (choice D) is not directly related to the Token Economy or its focus on behavior modification, making it an incorrect choice.

4. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?

• A. Hypernatremia
• B. Hypokalemia
• C. Myelosuppression
• D. Leukocytosis

Correct answer: B

Rationale: The correct answer is 'Hypokalemia.' The potassium level of 1.9 indicates low potassium levels, a condition known as hypokalemia. The other lab values are within normal ranges: Hgb 12.6, WBC 6500, uric acid 7.0, Na+ 136, and platelets 178,000. Hypernatremia (choice A) refers to high sodium levels, which are not present in this case. Myelosuppression (choice C) is a decrease in bone marrow activity, which is not indicated by the lab values provided. Leukocytosis (choice D) is an increase in white blood cells, which is also not present based on the given values.

5. After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:

• A. verbalizing the implied.
• B. seeking consensual validation.
• C. encouraging evaluation.
• D. suggesting collaboration.

Correct answer: B

Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.

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