Nursing Elites

1. The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?

• A. Insist that family members provide most of the patient's personal care.
• B. Maintain a personal space of at least 2 feet when assessing the patient.
• C. Ask permission before touching a patient during the physical assessment.
• D. Consider the patient's ethnicity as an important factor in planning care.

Correct answer: C

Rationale: Culturally appropriate nursing care requires sensitivity to the beliefs and practices of diverse cultural groups. Asking permission before touching a patient during a physical assessment is a universally respectful practice, as many cultures consider it disrespectful to touch a person without consent. This approach demonstrates respect for the patient's autonomy and cultural preferences. Maintaining a personal space of at least 2 feet can be a good practice for infection control or personal comfort but may not be culturally significant for all patients. Insisting that family members provide most of the patient's personal care may not align with the patient's cultural norms or preferences. Considering a patient's ethnicity as the most important factor in care planning overlooks the individuality of the patient and may lead to stereotyping or assumptions that are not accurate or helpful in providing tailored care.

2. When developing Jerry's plan of care, which of the following would NOT be helpful to include?

• A. Limiting choices
• B. Providing structure
• C. Encouraging patient input
• D. Ensuring availability of PRN medications

Correct answer: A

Rationale: Limiting choices would not be helpful in Jerry's plan of care. Providing options, even if among limited choices, offers the patient a sense of independence rather than imposing control. Providing structure is crucial, especially in transitioning from a psychiatric to a medical-surgical unit. Encouraging patient input in identifying triggers and effective methods for managing aggressive impulses is essential for empowerment and individualized care. Ensuring the availability and prompt delivery of PRN medications gives the patient a sense of control and security, assuring access to necessary medication when needed.

3. What feeling is likely to result from withdrawn behavior?

• A. Anger
• B. Paranoia
• C. Loneliness
• D. Boredom

Correct answer: C

Rationale: Withdrawn behavior involves avoiding social interactions and isolating oneself. This isolation can lead to feelings of loneliness as the individual lacks connection and companionship. While anger or paranoia may contribute to withdrawal, loneliness is a common emotional consequence of prolonged social isolation. Boredom may also arise from withdrawal if meaningful activities and social engagements are reduced.

4. Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:

• A. document the other worker's assessment of the patient.
• B. assess the patient based on data collected from all sources.
• C. validate the worker's impression by contacting the patient's significant other.
• D. discuss the worker's impression with the patient during the assessment interview

Correct answer: B

Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (Choice A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (Choice C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (Choice D) can introduce bias and may not lead to an objective evaluation.

5. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce embolism occurrence.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints, maintaining joint mobility, and preventing stiffness in immobile clients. This intervention helps preserve muscle strength and joint function. Options B, C, and D are incorrect because: Option B suggesting decreasing fluid intake to prevent diarrhea is not relevant to preventing complications of immobility and could lead to dehydration; Option C, massaging the client's legs to reduce embolism occurrence, is not a recommended practice as massage can dislodge blood clots and increase the risk of embolism; Option D, turning the client from side to back every shift, is not sufficient as it does not address the need for maintaining joint mobility and preventing contractures in immobile clients.

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