Nursing Elites

1. A woman who had a mastectomy is scheduled for a mastectomy peer support visit arranged by her primary health care provider. What is the purpose of the referral?

• A. To teach arm exercises
• B. To prevent social isolation
• C. To meet her physical needs
• D. To view her surgical incision

Correct answer: B

Rationale: The purpose of a mastectomy peer support visit is to prevent social isolation. This visit helps the client maintain her social connections and learn about community resources. Teaching arm exercises and meeting physical needs are tasks for healthcare professionals, not the primary goal of a peer support visit. Viewing the surgical incision is also not the primary purpose of such a visit.

2. A client is undergoing treatment for alcoholism. Twelve hours after their last drink, they develop tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: In alcohol withdrawal, stage 3 typically begins about 12-48 hours after the last drink. It includes symptoms from stages 1 and 2 like tremors, tachycardia, mild hallucinations, hyperactivity, and confusion. By stage 3, severe hallucinations and seizures can occur. Choice A, stage 1, is too early for the described symptoms. Stage 2, as described, is also too early as it typically occurs within 6-12 hours. Stage 4 is not a recognized stage in alcohol withdrawal protocols.

3. Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should monitor the client's serum sodium levels carefully when they have been on nasogastric (NG) tube suction for an extended period. Prolonged NG suctioning can lead to fluid loss and subsequent hyponatremia. Monitoring sodium levels is crucial to prevent complications. White blood cell count (Option A), albumin (Option B), and calcium (Option C) are not typically affected by prolonged NG suctioning. Therefore, these values are not the priority for monitoring in this situation.

4. The nurse develops a goal that makes a client feel as if they are engaging in a competition. Which type of motivation is the nurse using in this situation?

• A. Power motivation
• B. Affiliative motivation
• C. Avoidance motivation
• D. Achievement motivation

Correct answer: A

Rationale: The nurse is using power motivation in this situation. Power-motivated individuals tend to have assertive and aggressive behavior. By designing goals that make clients feel like they are in a competition, the nurse appeals to their need for power and accomplishment, even when they are competing against themselves. Affiliative motivation is characterized by nonassertive behavior and dependence on others, which is not applicable here. Avoidance motivation focuses on anxiety, fear of failure, and phobias, which are not relevant to the scenario. Achievement motivation does not involve aggressive behavior or the need for competition, making it an incorrect choice for this scenario.

5. Which client is most likely to be at risk for spiritual distress?

• A. Roman Catholic woman considering an abortion
• B. Jewish man considering hospice care for his wife
• C. Seventh-Day Adventist who needs a blood transfusion
• D. Muslim man who needs a total knee replacement

Correct answer: A

Rationale: The correct answer is the Roman Catholic woman considering an abortion. In the Roman Catholic faith, abortion is strictly prohibited, so making a decision regarding abortion can bring about spiritual distress. The Jewish faith does not have restrictions on hospice care. It is Jehovah's Witnesses, not Seventh-Day Adventists, who do not accept blood transfusions due to religious beliefs. Additionally, there are no religious prohibitions against joint replacement in the Muslim faith.

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