Nursing Elites

1. What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?

• A. Removing the child's undergarments
• B. Placing the child's toys on the bedside table
• C. Allowing the child to climb onto the stretcher
• D. Having the parents accompany the child to the operating suite

Correct answer: D

Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.

2. Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?

• A. Asking to speak to someone
• B. Asking to be alone
• C. Listening to music
• D. All of the above

Correct answer: D

Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.

3. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce embolism occurrence.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints, maintaining joint mobility, and preventing stiffness in immobile clients. This intervention helps preserve muscle strength and joint function. Options B, C, and D are incorrect because: Option B suggesting decreasing fluid intake to prevent diarrhea is not relevant to preventing complications of immobility and could lead to dehydration; Option C, massaging the client's legs to reduce embolism occurrence, is not a recommended practice as massage can dislodge blood clots and increase the risk of embolism; Option D, turning the client from side to back every shift, is not sufficient as it does not address the need for maintaining joint mobility and preventing contractures in immobile clients.

4. The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

• A. Low serum albumin level
• B. Low serum transferrin level
• C. High hemoglobin level
• D. High cholesterol level

Correct answer: A

Rationale: Long-term protein deficiency significantly lowers serum albumin levels. Albumin, derived from protein breakdown, is produced by the liver when adequate amino acids are available. Due to its long half-life, acute protein loss minimally affects serum albumin levels. In contrast, serum transferrin, with a shorter half-life of 8 to 10 days, decreases with acute protein deficiency and is not a reliable indicator of chronic protein malnutrition. Elevated hemoglobin levels may occur in conditions like dehydration or chronic obstructive pulmonary disease, making it an unreliable indicator of chronic protein malnutrition. High cholesterol levels are not directly linked to protein malnutrition and do not serve as a reliable indicator. Therefore, the most reliable indicator of chronic protein malnutrition among the options provided is a low serum albumin level.

5. A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?

• A. Client will verbalize that depression symptoms have lifted
• B. Client will identify life stressors that may be contributing to depression
• C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
• D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy

Correct answer: B

Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management. Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.

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