Nursing Elites

1. Which of the following is not one of the three universal spiritual needs?

• A. meaning and purpose
• B. love and relatedness
• C. forgiveness
• D. God's permission

Correct answer: D

Rationale: The three universal spiritual needs are meaning and purpose, love and relatedness, and forgiveness. These needs are commonly recognized across various belief systems and cultures. While the concept of God may be central to many religions, 'God's permission' is not considered a universal spiritual need. Seeking 'God's permission' is more specific to certain religious practices rather than a universally acknowledged spiritual need. Therefore, the correct answer is 'God's permission.' Choices A, B, and C are correct as they align with the generally accepted universal spiritual needs.

2. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:

• A. A cephalohematoma
• B. Molding
• C. Subdural hematoma
• D. Caput succedaneum

Correct answer: A

Rationale: The correct answer is A, a cephalohematoma. A cephalohematoma is an area of bleeding outside the cranium but beneath the periosteum, typically not crossing the suture line. Answer B, molding, is the overlapping of the bones of the cranium and does not involve bleeding, making it an incorrect choice. Answer C, a subdural hematoma, involves intracranial bleeding and is typically diagnosed through imaging studies like a CAT scan or x-ray. Answer D, caput succedaneum, is characterized by edema that crosses the suture line, unlike the described swelling in this case.

3. James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:

• A. denial
• B. suppression
• C. displacement
• D. fantasy

Correct answer: C

Rationale: Displacement is the transference of emotions, such as anger, to a substitute target that may be less threatening. In this scenario, James redirects his anger from the teacher to the dog. Denial is refusing to acknowledge an aspect of reality. Suppression is consciously putting aside unwanted thoughts or feelings. Fantasy involves imagining unrealistic scenarios. Therefore, in this case, the correct answer is displacement as James displaces his anger towards the dog.

4. When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?

• A. Constantly observing the client to prevent self-harm.
• B. Enlisting the client in defining and describing harmful behaviors.
• C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
• D. Removing all items from the environment that the client could use to harm themselves.

Correct answer: B

Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.

5. As a type of quality indicator, an example of a structure standard is:

• A. a written philosophy.
• B. a procedure for a straight catheterization.
• C. a protocol for treatment of a client with chest pain.
• D. the diagnostic work-up for a client with abdominal pain.

Correct answer: A

Rationale: The correct answer is 'a written philosophy.' Structure standards define the conditions needed to operate a system and do not directly involve client care. Examples include philosophy, objectives, goals, hours of operation, and management responsibility. Choices B, C, and D involve specific procedures and protocols related to client care, which are not structure standards.

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