Nursing Elites

1. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?

• A. Physical therapy for muscle strengthening exercises
• B. Physical therapy for range of motion exercises
• C. Occupational therapy to help her with confusion
• D. Medications to help her sleep more

Correct answer: A

Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.

2. Which of the following interventions should be prioritized in the care of the suicidal client?

• A. Remove all potentially harmful items from the client's room
• B. Allow the client to express feelings of hopelessness
• C. Note the client's capabilities to increase self esteem
• D. Set a "no suicide"? contract with the client

Correct answer: A

Rationale: accessibility of the means of suicide increases the lethality. Allowing a patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients but not specifically for suicide.

3. You are on the unit and overhear another nurse talking on the phone to a patient's friend who wants to see her patient who is comatose and on a ventilator. Since you cared for that patient yesterday, you know that the patient's significant other, who is also the designated healthcare surrogate (HCS) and has power of attorney (POA), has expressly stated that he wants this person on the list for restricted visitors. The nurse whispers that she'll call him to visit as soon as the significant other has gone home. What should your first response be?

• A. Inform the significant other
• B. Report the nurse to the nurse manager
• C. Speak with the nurse directly in private
• D. Call the visitor and tell him he can't visit

Correct answer: C

Rationale: Speaking with the nurse directly and privately is the most constructive manner in which to handle this situation and advocate for the significant other's wishes. Doing so will open communication with a peer and build the relationship, instead of alienating the other nurse by taking action that does not involve her and will cast her in a negative light with others. It is essential to express your concerns regarding honoring the significant other's requests and rights regarding the limitation of visitors. Option A is incorrect because the significant other is not the one trying to visit, and it is more appropriate to address the nurse directly first. Option B is not the best initial response as it may escalate the situation without giving the nurse a chance to correct the issue. Option D is incorrect as it does not address the issue at its source and may create further conflict without resolving the underlying problem.

4. A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?

• A. Observation
• B. Reflection
• C. Summarizing
• D. Validating

Correct answer: B

Rationale: The nurse is demonstrating the therapeutic communication technique of reflection. In this scenario, the nurse is redirecting the question back to the client, encouraging them to explore their thoughts and feelings about the situation. Reflection involves restating a statement or question in a way that prompts the client to consider their own answers, fostering self-awareness and insight. Observation involves stating facts, summarizing involves condensing information, and validating involves confirming the client's feelings or experiences, none of which are demonstrated in this interaction.

5. Richard is a 72-year-old with stage 4 lung cancer who has been admitted to the hospital for pneumonia. He is alert and oriented and states he would like to sign a do not resuscitate (DNR) order. His wife enters the room after he has signed it and is very upset that he has made this decision without discussing it with her. She wants to know what she can do to get the DNR reversed. What should your first response be?

• A. Contact the unit manager to talk with her
• B. Contact the hospital's attorney to discuss with her
• C. Try to talk Richard out of his decision
• D. Offer caring support for both parties

Correct answer: D

Rationale: The correct response in this situation is to offer caring support for both parties. Richard, being alert and oriented, has the right to make his own decisions, including signing a do not resuscitate (DNR) order. It is important to respect his autonomy while also acknowledging his wife's feelings. By offering caring support, the nurse can facilitate a discussion between Richard and his wife, helping them navigate their emotions and decisions. Contacting the unit manager or hospital's attorney would not be appropriate as the initial response. These actions may escalate the situation and are not focused on addressing the emotional needs of the couple. Trying to talk Richard out of his decision would disregard his autonomy and right to make choices about his own care, which goes against ethical principles of patient autonomy and informed decision-making.

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