Nursing Elites

1. When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?

• A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.

2. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?

• A. "I don't remember anything about what happened to me."?
• B. "I'd rather not talk about it right now."?
• C. "It's the other entire guy's fault! He was going too fast."?
• D. "My mother is heartbroken about this."?

Correct answer: A

Rationale: The correct answer is, '"I don't remember anything about what happened to me."?' Suppression involves willfully putting an unacceptable thought or feeling out of one's mind. In this case, the client is purposely choosing not to remember details of the traumatic event to avoid dealing with the associated emotions. Choice B, '"I'd rather not talk about it right now,"?' suggests avoidance or deflection rather than active suppression. Choice C, '"It's the other entire guy's fault! He was going too fast,"?' indicates blaming someone else for the situation, which is a form of defense mechanism known as externalization. Choice D, '"My mother is heartbroken about this,"?' expresses empathy towards the mother's emotions and does not demonstrate suppression of personal feelings.

3. An older woman has lived alone since the death of her husband 10 years ago, and she has a long list of vague complaints. Which assessment is the priority for the home health nurse to perform?

• A. Assess for feelings of loneliness and isolation.
• B. Determine if the client has unresolved grief.
• C. Determine if there are safety issues.
• D. Ask about the availability of support systems.

Correct answer: C

Rationale: The priority assessment for the home health nurse in this scenario is to determine if there are safety issues. The client is an older woman living alone with a long list of vague complaints, indicating several risk factors. Ensuring her safety should be the primary concern. While assessing for feelings of loneliness, isolation, or grief is important, ensuring the client's safety takes precedence due to her vulnerable situation. Although assessing the availability of support systems is essential in a home health assessment, safety issues must be addressed first given the client's profile.

4. The best way for a healthcare provider and a healthcare facility to control the effects of poor and disruptive patient behavior is to _________________.

• A. prevent it
• B. restrain the patient
• C. medicate the patient
• D. isolate the patient

Correct answer: A

Rationale: The most effective approach to managing poor and disruptive patient behavior is by preventing it proactively. This involves implementing strategies, communication techniques, and environmental modifications that address the underlying causes of the behavior. Restraint, medication, and isolation should only be used as a last resort when the patient or others are at risk of harm. Restraint and isolation are primarily used to ensure safety, while medication, especially when used solely to control behavior, can have adverse effects and is considered a measure of last resort. Therefore, prevention is crucial in promoting a therapeutic environment and fostering positive patient outcomes.

5. When observing an infant lying quietly in the bassinet with eyes open wide, what action should the nurse take in response to the infant's behavior?

• A. Brightening the lights in the room
• B. Encouraging the mother to talk to her baby
• C. Wrapping and then turning the infant to the side
• D. Beginning physical and behavioral assessments

Correct answer: B

Rationale: When an infant is lying quietly in a bassinet with eyes open wide, it indicates a quiet, alert state. This state is optimal for infant stimulation and interaction. Bright lights can be disturbing to newborns and may disrupt the mother-infant interaction. Wrapping and turning the infant to the side is typically done for a sleeping infant. While physical and behavioral assessments are important, in this scenario, the priority is to encourage mother-infant bonding and communication, as it is a valuable opportunity for interaction and stimulation.

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