Nursing Elites

1. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.

• A. Hopelessness
• B. Power
• C. Interrupted sleep pattern
• D. Disturbed self-esteem

Correct answer: A

Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.

2. The supervising RN asks you to bring the unit's collected lab specimens to the lab 'stat'. You should ______________.

• A. not decline this task because nurses do not handle 'stats'.
• B. run this errand as promptly as possible
• C. run this errand immediately and without delay
• D. Complete this task before the end of your shift or after your lunch.

Correct answer: C

Rationale: In healthcare settings, 'stat' is commonly used to indicate that something should be done immediately and without any delay. It is a critical term used to prioritize urgent tasks. Nurses are responsible for various tasks, including handling urgent requests such as transporting lab specimens promptly. Option A is incorrect as nurses can handle urgent tasks like 'stats'. Option B is not as specific as option C, which clearly emphasizes the need for immediate action. Option D is incorrect as it suggests delaying the task until later, which goes against the urgency implied by the term 'stat'.

3. In which of the following ways can a healthcare provider promote the sense of taste for an older adult?

• A. Mixing foods together on the dinner tray
• B. Avoiding cologne, air fresheners, or room deodorizers
• C. Encouraging the client to chew food thoroughly
• D. Discouraging the use of salt or seasonings with prepared food

Correct answer: C

Rationale: As individuals age, their sense of taste may diminish, impacting the enjoyment of eating. One effective way for a healthcare provider to promote the sense of taste for an older adult is by encouraging them to chew food thoroughly. Thorough chewing increases the contact of food with the taste buds, enhancing the chances of experiencing the flavors. Mixing foods together on the dinner tray may not necessarily enhance taste perception. Avoiding strong scents like cologne, air fresheners, or room deodorizers is more related to olfactory senses rather than taste. Discouraging the use of salt or seasonings can further diminish the taste experience for older adults who may already have reduced taste sensitivity.

4. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?

• A. Assist the client in using the bathroom one hour after going to bed
• B. Give the client a massage before bedtime
• C. Tuck bed sheets and blankets tightly around the client once settled in bed
• D. Give the client a pair of socks to wear if their feet become cold

Correct answer: D

Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.

5. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?

• A. Perform nursing activities throughout the entire shift
• B. Assess for signs of increased muscle tone
• C. Minimize environmental noise
• D. Teach clients to perform the Valsalva maneuver

Correct answer: C

Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.

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