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 is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?

• A. Increasing the infant's fluid intake
• B. Maintaining the infant's body temperature at 98.6�F
• C. Minimizing tactile stimulation
• D. Decreasing caloric intake

Correct answer: A

Rationale: Bilirubin is excreted through the kidneys, therefore increasing fluid intake can help facilitate its elimination. Maintaining the infant's body temperature is important for overall health but does not directly assist in eliminating bilirubin, making choice B incorrect. Choices C and D are irrelevant to bilirubin elimination in this scenario and do not address the specific issue of physiologic jaundice.

3. 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.

4. Client self-determination is the primary focus of:

• A. malpractice insurance
• B. nursing's advocacy for clients
• C. confidentiality
• D. health care

Correct answer: B

Rationale: Client self-determination refers to the right of clients to make their own decisions about their health care. Nursing's advocacy for clients focuses on upholding this right by supporting and respecting the autonomy and self-determination of clients. This advocacy ensures that clients are empowered to participate in decision-making regarding their health. Confidentiality, while essential, is about maintaining the privacy of client information. Malpractice insurance is a protective measure for professionals in case of errors or negligence. Health care, though crucial for enabling client self-determination, is a broad term encompassing various services and not the primary focus when discussing the client's right to autonomy.

5. A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?

• A. "I can drink alcohol now that I am decreasing my Xanax."?
• B. "I should not take another Xanax pill. Here is what is left of my last prescription."?
• C. "I should take three pills per day next week, then two pills for one week, then one pill for one week."?
• D. "I can expect to be sleepy for several days after stopping the medicine."?

Correct answer: C

Rationale: Explanation: When discontinuing alprazolam (Xanax) after long-term use, it is crucial to taper the dosage gradually to prevent withdrawal symptoms. The correct statement indicates an understanding of this by planning a structured decrease in dosage over time. Choice A is incorrect as drinking alcohol while decreasing Xanax can be dangerous and is not recommended. Choice B is incorrect as abruptly stopping Xanax is not safe and can lead to withdrawal symptoms. Choice D is incorrect as expecting to be sleepy for several days after stopping the medication does not address the need for a gradual tapering process to avoid withdrawal symptoms.

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