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. A toddler is 26 months old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the toddler in?

• A. Trust vs. mistrust
• B. Initiative vs. guilt
• C. Autonomy vs. shame and doubt
• D. Intimacy vs. isolation

Correct answer: C

Rationale: The correct stage for a toddler who is 26 months old, according to Erik Erikson's stages of psychosocial development, is Autonomy vs. shame and doubt. This stage occurs between 18 months to 3 years of age. During this stage, children are focused on developing a greater sense of control and independence. Choice A, Trust vs. mistrust, is the first stage occurring from birth to 18 months, where infants learn to trust or mistrust their caregivers based on their care. Choice B, Initiative vs. guilt, is the third stage occurring from 3 to 5 years, where children start to assert themselves more. Choice D, Intimacy vs. isolation, is a stage occurring in adulthood, not relevant to a toddler's development.

3. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.

4. According to the CDC, which of the following age groups is most likely to meet the criteria for major depression?

• A. 18-24 years
• B. 25-34 years
• C. 35-44 years
• D. 45-64 years

Correct answer: D

Rationale: According to the CDC, individuals aged 45-64 years are most likely to meet the criteria for major depression. While patients in the 18-24 year age group are more likely to report symptoms of depression, when it comes to major depression, the prevalence is higher in the 45-64 year age group. Choices A, B, and C are incorrect because the CDC indicates that major depression is most prevalent in the 45-64 year age group.

5. When performing a cultural assessment with a patient from a different culture, what action should the nurse take first?

• A. Request an interpreter before interviewing the patient
• B. Wait until a family member is available to help with the assessment
• C. Ask the patient about any affiliation with a particular cultural group
• D. Tell the patient what the nurse already knows about the patient's culture

Correct answer: B

Rationale: When conducting a cultural assessment, the first step is to inquire if the patient has any affiliation with a specific cultural group. This helps the nurse understand the patient's background and beliefs. Requesting an interpreter before interviewing the patient may be necessary if language barriers exist. Waiting for a family member to assist with the assessment may delay the process and compromise patient confidentiality. Telling the patient what the nurse knows about their culture assumes knowledge and may lead to misunderstandings or inaccuracies.

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