Nursing Elites

1. While planning care for a 2-year-old hospitalized child, which situation would the nurse most likely expect to affect the behavior?

• A. Strange bed and surroundings.
• B. Separation from parents.
• C. Presence of other toddlers.
• D. Unfamiliar toys and games.

Correct answer: B

Rationale: The correct answer is 'Separation from parents.' Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. Choices A, C, and D are incorrect because while strange bed and surroundings, presence of other toddlers, and unfamiliar toys and games may contribute to some level of stress or discomfort, the separation from parents is the primary factor affecting the behavior of a 2-year-old hospitalized child.

2. A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?

• A. I'm sorry to hear that.'
• B. 'Oh, you have a lot of good years left.'
• C. 'You are concerned about your sex life?'
• D. 'Have you asked your primary health care provider about that?'

Correct answer: C

Rationale: The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I'm sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.

3. The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother-infant bonding?

• A. Asking the mother to change her baby's diaper
• B. Assuring the mother that her baby is receiving excellent care
• C. Encouraging the mother to touch her baby whenever possible
• D. Keeping the mother informed about the care the nursing staff is providing her baby

Correct answer: C

Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother-infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother-infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby's diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.

4. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

• A. Only refer to the client by gender
• B. Identify the client only by age
• C. Avoid using the client's name
• D. Discuss the client another time

Correct answer: D

Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.

5. The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

• A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
• B. Sit quietly in the client's room until the client leaves the bathroom.
• C. Allow the client to cry alone and leave the client in the bathroom.
• D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.

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