Nursing Elites

1. While receiving a preoperative enema, a client starts to cry and says, 'I'm sorry you have to do this messy thing for me.' Which is the nurse's best response?

• A. I don't mind it.'
• B. 'You seem upset.'
• C. 'This is part of my job.'
• D. 'Nurses get used to this.'

Correct answer: B

Rationale: The nurse's best response in this situation is to acknowledge the client's emotional state, as it shows empathy and encourages further expression of feelings. Choice A, 'I don't mind it,' dismisses the client's emotions and does not address the underlying issue. Choice C, 'This is part of my job,' focuses on the task rather than the client's emotional needs. Choice D, 'Nurses get used to this,' minimizes the client's feelings and lacks empathy. By selecting choice B, 'You seem upset,' the nurse acknowledges the client's distress and opens the door for further communication and support.

2. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?

• A. Determine how well the client can change the dressing.
• B. Ask the client to demonstrate the procedure.
• C. Seek a family member's opinion on the client's dressing change ability.
• D. Observe the client change the dressing unassisted.

Correct answer: D

Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.

3. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

• A. Remind the child to clean his genital area.
• B. Defer perineal care because of the child's age.
• C. Retract the foreskin gently to cleanse the penis
• D. Ask the parents why the child is not circumcised

Correct answer: C

Rationale: When bathing an uncircumcised boy older than 3 years, it is essential to gently retract the foreskin to cleanse the penis. This helps in preventing the buildup of bacteria and maintaining good hygiene. Reminding the child to clean his genital area (Option A) may not be effective due to the child's cognitive development level. Perineal care should not be deferred (Option B) as it is necessary for maintaining hygiene at any age. Asking the parents why the child is not circumcised (Option D) is not relevant to the immediate care required during bathing.

4. 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.

5. 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.

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