Nursing Elites

1. Which of the following examples indicates that the nurse is giving recognition as a form of therapeutic communication?

• A. You need to take your medicine now, Adam.
• B. Jill, your father is trying to make amends with you.
• C. The physician wants to meet with you and your husband, Amy.
• D. Linda, you brushed your hair this morning.

Correct answer: A

Rationale: Recognition is a form of therapeutic communication in which the nurse points out a positive aspect of the client's behavior. Noting that a client brushed her hair herself indicates that the nurse recognizes the client's attempts at self-care. This recognition shows the client that the nurse is paying attention and may be open to further communication. Choices A, B, and C do not demonstrate recognition. Choice A focuses on a directive statement, Choice B involves informing the client about a situation without acknowledging their actions, and Choice C informs the client about a meeting without providing recognition for any behavior.

2. A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client's reaction?

• A. Reflection
• B. Regression
• C. Repudiation
• D. Reconciliation

Correct answer: C

Rationale: The client's reaction of believing that only minor surgery is necessary when faced with the need for an abdominoperineal resection and a colostomy is an example of repudiation. Repudiation involves a refusal to acknowledge anticipated loss as a defense mechanism against the overwhelming stress of illness. The client is psychologically denying the seriousness of the situation. The other choices are incorrect because: - Reflection (Choice A) does not apply since the client is not contemplating the issues of the situation. - Regression (Choice B) is not demonstrated as the client's behavior does not indicate reverting to an earlier stage of development. - Reconciliation (Choice D) is not applicable as the client has not made a realistic adjustment to the illness but rather is in denial of its severity.

3. Which priority action would the nurse manager use to help the nurse who may be experiencing burnout?

• A. Transfer the nurse to another unit in the facility.
• B. Help the nurse choose a position on a low-stress unit.
• C. Encourage the nurse to attend educational programs.
• D. Help the nurse identify personal responses to job stress.

Correct answer: D

Rationale: The correct priority action for the nurse manager to help a nurse experiencing burnout is to assist the nurse in identifying personal responses to job stress. This involves recognizing work stressors in the environment and evaluating coping strategies to determine their effectiveness. While transferring the nurse to another unit could be a solution, the initial focus should be on self-awareness and coping strategies. Choosing a position on a low-stress unit and attending educational programs can be beneficial in reducing burnout, but they are not the primary steps to address burnout when it occurs.

4. 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.

5. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and compare the reading with the client's previously documented blood pressure readings for accuracy.
• B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort during blood pressure measurement.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first when a client's blood pressure reading is 156/94 mm Hg is to compare the current reading with the client's previously documented readings. This comparison helps determine whether the current reading is abnormal for the client. Option A, which involves informing the client that the blood pressure is high and comparing it with the previous readings, is appropriate as it educates the client and aids in accurate assessment. Option B, contacting the health care provider for medication, is premature without further assessment. Option C, replacing the cuff with a larger one, is incorrect as it may affect the accuracy of the blood pressure measurement and is not a standard practice for managing high blood pressure readings.

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