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. Which of the following attitudes is essential in a nurse who assists clients during crises?

• A. viewing crisis intervention as the first step in solving bigger problems
• B. wanting to help clients solve all problems identified
• C. taking an active role in guiding the process
• D. feeling that work requires identification with all of a client's problems

Correct answer: A

Rationale: Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. This approach focuses on addressing the immediate crisis first, which can potentially prevent the escalation of bigger problems. Wanting to help clients solve all problems identified (Choice B) may not be feasible or necessary during a crisis situation where immediate intervention is crucial. Taking an active role in guiding the process (Choice C) is important, but the primary focus should be on crisis intervention. Feeling that work requires identification with all of a client's problems (Choice D) may lead to a lack of focus on the immediate crisis at hand.

3. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?

• A. "My skin is always so dry."?
• B. "I often use a laxative for constipation."?
• C. "I have always liked to drink a lot of iced tea."?
• D. "I sometimes have a problem with dribbling urine."?

Correct answer: B

Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.

4. When caring for a Native-American family, what does the nurse need to consider?

• A. The family may consist of extended family members beyond parents and children.
• B. Native Americans tend to value their heritage and traditions.
• C. Some Native Americans use herbs and psychologic treatments for illnesses.
• D. Health care practices vary among different tribes and individuals.

Correct answer: C

Rationale: When caring for a Native-American family, it is crucial to acknowledge and respect their cultural beliefs and practices. Choice A, while relevant, is not as specific as understanding the use of herbs and psychologic treatments in Native American healing practices. Choice B, though generally true, does not directly impact the nursing care provided. Choice D, although true, is too broad and does not focus on the specific aspect of treatment practices. Choice C is the most appropriate answer as it highlights the importance of recognizing and incorporating traditional healing methods into the nursing care plan, promoting culturally sensitive and holistic care.

5. When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, what should the nurse do?

• A. confront the staff member immediately and say, "You know that is not the treatment plan."?
• B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
• C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
• D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.

Correct answer: C

Rationale: When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, it is crucial to address the issue promptly and effectively. Confronting the staff member immediately in front of the client may worsen the situation by enhancing the division of staff and compromising client care. Writing an incident report, although important for documentation, may not address the immediate need to correct the behavior. Bringing up the incident during a weekly conference may not be the most effective approach for immediate resolution. Asking the staff member to talk in private and reinforcing how antisocial clients try to divide staff is the best option. This approach allows for a constructive conversation to address the issue, provide education, and help the staff member develop skills to work effectively with this client population.

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