Nursing Elites

1. The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:

• A. Have decreased anxiety.
• B. Talk to the nurse for 10 minutes.
• C. Sit quietly for 30 minutes.
• D. Develop an adaptive coping mechanism.

Correct answer: B

Rationale: When developing outcome criteria for a client with severe anxiety, it is crucial for the goals to be specific, measurable, and realistic. In this scenario, the most appropriate outcome is for the client to talk to the nurse for 10 minutes within 4 days. This goal is specific (talking for a defined duration), measurable (10 minutes), and realistic given the client's condition. Expecting a severely anxious client to sit quietly for 30 minutes is not realistic and may even exacerbate their anxiety. While developing an adaptive coping mechanism is important, it is a broader long-term goal and may not be achievable within the specified timeframe. Having decreased anxiety is a desirable outcome, but it lacks specificity and measurability, making it less suitable as an immediate goal.

2. A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?

• A. She dresses herself
• B. She pulls a toy behind her
• C. She can build a tower of eight blocks
• D. She can copy a horizontal or vertical line

Correct answer: B

Rationale: The correct answer is 'She pulls a toy behind her.' This behavior is consistent with the developmental stage of an 18-month-old who enjoys push-pull toys. Dressing oneself usually begins around 3 years old, building a tower of eight blocks at approximately 3 years old, and copying a horizontal or vertical line at about 4 years old. Choices A, C, and D are incorrect as they represent skills that are typically observed in older children.

3. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:

• A. Offering hard candy
• B. Administering analgesic medications
• C. Splinting swollen joints
• D. Providing saliva substitute

Correct answer: D

Rationale: Xerostomia is dry mouth, a common side effect in cancer patients. Providing a saliva substitute helps alleviate the discomfort associated with dry mouth by moistening the oral mucosa. Offering hard candy, as mentioned in choice A, can worsen xerostomia by increasing sugar content and potentially causing irritation. Administering analgesic medications, as in choice B, is not directly related to treating dry mouth. Splinting swollen joints, as in choice C, is irrelevant to xerostomia, which primarily affects the oral cavity.

4. Support-system enhancement includes all of the following except:

• A. determining the barriers to using support systems.
• B. discussing ways to help others who are concerned.
• C. exploring life problems of the support-team members.
• D. involving spouse, family, and friends in the care and planning.

Correct answer: C

Rationale: Support-system enhancement involves various strategies to strengthen the support system. Determining the barriers to using support systems, discussing ways to help others who are concerned, and involving spouse, family, and friends in the care and planning are all essential aspects of enhancing the support system. However, exploring the life problems of the support-team members is not directly related to enhancing the support system. This approach could potentially invade personal boundaries and may not be necessary for improving the support system, making it the correct answer in this case. Therefore, option C is the correct answer as it does not align with the appropriate methods of support-system enhancement.

5. An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?

• A. "I think I was a lonely child because I could not tell anyone about my abuse."?
• B. "I am now aware of how deep-seated my anger is. Before, I did not realize I was angry."?
• C. "The program has given me the courage to tell my mother how I felt about her role in my hurt."?
• D. "There are so many people just like me, who are just normal people that had bad things happen to them."?

Correct answer: B

Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.

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