Nursing Elites

1. What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?

• A. Suggest that the client requesting attention speak with another staff member.
• B. Leave the new client, saying, 'I'll talk with the other client until things calm down.'
• C. Introduce the two clients and suggest that the client join them on a tour of the facility.
• D. Say to the interrupting client, 'I'll be back to talk with you after I orient this new client.'

Correct answer: D

Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client. Therefore, the correct approach is to say to the interrupting client, 'I'll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries. Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.

2. When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?

• A. Check the bath water temperature.
• B. Shut the bathroom door.
• C. Ensure that the client has voided.
• D. Provide extra towels.

Correct answer: A

Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.

3. Which intervention should the nurse use for a client who hallucinates, yells, and curses throughout the day?

• A. Ignore the client's behavior if the client is not harming anyone.
• B. Isolate the client until the behavior decreases or stops.
• C. Explain how the behavior affects other people on the unit.
• D. Seek to understand what the behavior means to the client.

Correct answer: D

Rationale: When a client experiences hallucinations, yells, and curses, it is essential to seek to understand the underlying meaning of their behavior. All behavior has significance, and understanding the client's perspective can guide appropriate interventions. Ignoring the behavior may exacerbate the situation and isolating the client could lead to increased anxiety and further acting out. Explaining the impact on others is not helpful in this scenario as the client is not intentionally hallucinating; yelling and cursing are responses to the hallucinations.

4. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

• A. Review the client's weight pattern over the year
• B. Ask the mother to record her diet for the last 24 hours
• C. Encourage her to talk about her view of herself
• D. Give her several pamphlets on postpartum nutrition

Correct answer: C

Rationale: Encouraging the adolescent client to talk about her view of herself is the first action the nurse should take. Body image is crucial for adolescents, especially after pregnancy. By addressing the client's concerns about her weight and discussing her self-perception, the nurse can provide emotional support and open a dialogue for further assessment and teaching. Choice A, 'Review the client's weight pattern over the year,' is not the priority at this time as the client's immediate concern is her post-pregnancy weight. Choice B, 'Ask the mother to record her diet for the last 24 hours,' focuses on dietary habits rather than addressing the client's emotional concerns. Choice D, 'Give her several pamphlets on postpartum nutrition,' may be helpful but should come after addressing the client's emotional needs and concerns.

5. On her first visit to the neonatal intensive care unit to see her preterm newborn, the mother's only comment to the nurse is, 'My baby looks so fragile. Do you think my child will make it?' Which is the most appropriate response by the nurse?

• A. "Many infants born as small as yours have done just fine."
• B. "The staff is confident in your child's prognosis because preterm babies do look like this at first."
• C. "It's understandable that your baby looks fragile to you. What have you learned about the condition?"
• D. "Your baby is not as fragile as it appears. Do you find it so frightening that you can't touch your child?"

Correct answer: C

Rationale: The nurse's response should aim to convey acceptance and encourage the mother to express her concerns. By saying, "It's understandable that your baby looks fragile to you. What have you learned about the condition?", the nurse acknowledges the mother's feelings and prompts her to share her understanding, fostering further communication and addressing any misconceptions. Choices A and B dismiss the mother's concerns by making general statements and do not encourage dialogue. Choice D implies judgment and may deter the mother from opening up about her fears.

Similar Questions