Nursing Elites

1. Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

• A. Explains the goals of the procedure
• B. Displays few signs of anticipatory grief
• C. Participates in learning perioperative care
• D. Verbalizes acceptance of permanent dependency needs

Correct answer: C

Rationale: Participating actively in learning self-care demonstrates emotional acceptance of the need for surgery and readiness for planning post-surgery. Explaining the goals of the procedure may reflect intellectual readiness but not necessarily emotional readiness. A client who shows few signs of anticipatory grief may be suppressing emotions or in denial, which can hinder the emotional readiness. Verbalizing acceptance of permanent dependency needs suggests the client may require further education and emotional support, as it may not reflect a healthy emotional readiness for the surgery.

2. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

• A. Record the amount on the client's fluid output record.
• B. Encourage the client to increase oral fluid intake.
• C. Notify the healthcare provider of the findings.
• D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The correct action for the nurse to take next is to record the amount of urine output on the client's fluid output record. The urine color and volume are within normal limits, indicating adequate hydration. There is no indication of a need to encourage increased oral fluid intake or notify the healthcare provider as the findings are normal. Palpating the client's bladder for distention is unnecessary in this scenario since the client has successfully voided a normal amount of urine after 4 hours.

3. Which parental statement would the nurse recognize as the appropriate application of time-out when disciplining a 4-year-old?

• A. I send my child to their bedroom for misbehaving.
• B. We limit time-out to 4 minutes per incident.
• C. Putting my child in a dark closet for time-out is very effective.
• D. I explain the reason for the time-out before and after disciplining my child.

Correct answer: D

Rationale: The correct answer is to explain the reason for the time-out before and after disciplining the child. This approach reinforces the child's association of the time-out with the undesirable behavior, helping the child learn to control those behaviors. Sending a child to their bedroom may lead to negative associations with bedtime or be ineffective if the child enjoys spending time in their bedroom. Time-out should ideally be limited to 1 minute per year of age, so a time-out for a 4-year-old should be limited to 4 minutes. Placing a child in a dark closet can create fear and damage the child's trust in their parents as a source of safety, making it an inappropriate and harmful approach. Even if this method seems effective in the short term, the potential long-term consequences outweigh any immediate benefits.

4. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?

• A. 'You may not have enough energy before long to hold a big party.'
• B. 'Do you mean to say that you want to plan your funeral and wake?'
• C. 'Planning a party and thinking about all your friends sounds like fun.'
• D. 'You should be thinking about spending your last days with your family.'

Correct answer: C

Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.

5. Which mental health disorder is most likely to be treated with electroconvulsive therapy (ECT)?

• A. Clinical depression
• B. Substance abuse disorder
• C. Antisocial personality disorder
• D. Psychosis occurring in schizophrenia

Correct answer: A

Rationale: Electroconvulsive therapy (ECT) is commonly used to treat severe cases of clinical depression in individuals who have not responded well to psychotropic medications or when immediate intervention is necessary due to the severity of the depression. ECT is not typically a first-line treatment for substance abuse disorders, antisocial personality disorder, or psychosis occurring in schizophrenia. Clients with clinical depression who meet specific criteria and have not benefited from other treatments may be considered for ECT to alleviate symptoms and improve overall functioning.

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