Nursing Elites

1. Which source of stress would the nurse anticipate in a 5-year-old client?

• A. Jealousy
• B. Stubbornness
• C. Procrastination
• D. Companionship

Correct answer: C

Rationale: Procrastination, which refers to delaying completing chores or activities, is a common source of stress for 5-year-old clients. At this age, children may start experiencing stress related to the pressure of tasks or expectations. Jealousy and stubbornness are more typical sources of stress for 3- and 4-year-old clients who are still developing social and emotional skills. Companionship, on the other hand, is generally seen as a positive aspect in a child's life and is not typically a source of stress but rather a source of support and comfort.

2. A 17-year-old Asian client is being seen for lower abdominal pain in the right quadrant. The client is accompanied by his parents. The nurse notes that the client's father does not make eye contact and shows little response when told that the client will need surgery. Which of the following is the most appropriate action of the nurse?

• A. Contact an interpreter to give the information again in the father's native language
• B. Continue to provide information about surgery to both the client and his parents
• C. Call social services to evaluate the parent's standard of care
• D. Contact the physician about postponing the surgery

Correct answer: B

Rationale: Nurses may work with clients who have varying cultural beliefs. Because of this, nurses must remain aware of the cultural practices associated with certain ethnic groups. Asian Americans may avoid eye contact as a sign of respect; additionally, emotional responses may be avoided except for in private situations. If this family did not have a language barrier, the nurse should continue to provide appropriate information about the surgery and recognize the cultural differences that exist. Contacting an interpreter is not necessary as there was no mention of a language barrier. Calling social services to evaluate the parent's standard of care is premature and not within the nurse's immediate scope of practice. Contacting the physician about postponing the surgery is not warranted based on the information provided.

3. Which of the following outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

• A. The client will verbalize community resources from which to seek shelter after discharge.
• B. The client will write a plan to keep herself and her children safe.
• C. The client will contact an attorney for help with pressing charges.
• D. The client will be safe and receive treatment for injuries.

Correct answer: D

Rationale: During the crisis stage of caring for a victim of domestic violence, the immediate priority is ensuring the client's safety and providing treatment for any injuries sustained. This focuses on addressing the urgent physical and emotional needs of the victim. While options like verbalizing community resources or creating safety plans are important for long-term support, they are not the primary concerns during the crisis phase. Contacting an attorney for legal assistance, though vital in the future, is not the immediate priority during the crisis stage when the client's safety and health are at the forefront.

4. When administering medications through a nasogastric tube connected to low intermittent suction, which action should the nurse do first?

• A. Clamp the nasogastric tube
• B. Confirm placement of the tube
• C. Use a syringe to instill the medications
• D. Turn off the intermittent suction device

Correct answer: D

Rationale: When administering medications through a nasogastric tube connected to low intermittent suction, the nurse should first turn off the intermittent suction device. This step is crucial to prevent the medications from being immediately suctioned out before they can be absorbed. Clamping the nasogastric tube is not the initial action because it may cause pressure buildup and lead to complications. Confirming the placement of the tube is important but should not be the first step in this scenario. Using a syringe to instill the medications comes after ensuring the suction is turned off to enable proper administration and absorption of the medications.

5. Which is a true statement regarding stress related disorders?

• A. Stress related disorders are only caused by stress
• B. Symptoms of stress related disorders would not exist if the client was not experiencing stress
• C. Stress related disorders are also called psycho-physiologic disorders
• D. None of the above

Correct answer: C

Rationale: The correct answer is that stress related disorders are also called psycho-physiologic disorders. These disorders have a physiologic basis for their development, but stress can exacerbate the symptoms. While stress plays a significant role in these disorders, they are not solely caused by stress. Choice A is incorrect as stress is a contributing factor rather than the sole cause. Choice B is incorrect because symptoms of stress related disorders can persist even when the individual is not actively experiencing stress. Choice D is incorrect as there is a true statement among the choices, which is that stress related disorders are also known as psycho-physiologic disorders.

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