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. The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?

• A. Use Liquid PaperTM to 'white out' the resolved diagnosis on the care plan
• B. Recopy the care plan without the resolved diagnosis
• C. Write a nursing progress note indicating that the outcome goals have been achieved
• D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

Correct answer: D

Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.

3. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

• A. Reassure the client that many obese individuals have concerns about sex.
• B. Remind the client that sexual relationships can remain unaffected by obesity.
• C. Determine the frequency of sexual intercourse.
• D. Ask the client to talk about specific concerns.

Correct answer: D

Rationale: Option D is the best response as it allows the client to express her specific concerns, providing the nurse with valuable assessment data. This open-ended question encourages the client to share her worries and feelings, which can guide the nurse in addressing her unique needs. Options A and B make assumptions about the client's concerns based on her weight, potentially invalidating her feelings and inhibiting effective communication. Option C is premature as understanding the client's concerns should precede discussions about the frequency of sexual intercourse, which may not address the core issues the client is facing.

4. While explaining an illness to a 10-year-old, what should the nurse keep in mind about cognitive development at this age?

• A. They are able to make simple associations of ideas.
• B. They are able to think logically in organizing facts.
• C. Interpretation of events originates from their own perspective.
• D. Conclusions are based on previous experiences.

Correct answer: B

Rationale: The correct answer is that 10-year-olds are able to think logically in organizing facts. At this age, children are in the concrete operational stage according to Piaget's theory of cognitive development. In this stage, they can understand and organize information logically and can manipulate objects mentally. Choice A is incorrect because simple associations of ideas are more characteristic of earlier developmental stages. Choice C is incorrect as it refers to egocentrism, which is more typical of the preoperational stage. Choice D is incorrect as basing conclusions on previous experiences is a broader concept that applies across different ages and stages of development, rather than being specific to 10-year-olds in the concrete operational stage.

5. Which behavior would the nurse recognize as developmentally atypical in preschoolers?

• A. Thumb sucking during stress
• B. Feeling guilty for behaving inappropriately
• C. Feeling happy if there is a newborn in the family
• D. Curiosity about their surroundings

Correct answer: C

Rationale: The correct answer is feeling happy if there is a newborn in the family. Preschoolers are more likely to exhibit feelings of stress and jealousy rather than happiness with the arrival of a new baby in the family. Thumb sucking and bed-wetting are common behaviors displayed by preschoolers during times of stress. Guilt typically arises in children when they perceive that they have not behaved appropriately. Preschoolers are known to be naturally curious about their surroundings, showing an interest in exploring and learning about the environment around them. Therefore, feeling happy with the birth of a new baby is developmentally atypical for preschoolers.

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