Nursing Elites

1. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

• A. Teach the daughter instead
• B. Teach both and ask the daughter to translate for you
• C. Contact a home health agency to provide care
• D. Provide a pamphlet with detailed instructions

Correct answer: B

Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.

2. A nurse is using active listening as a form of therapeutic communication when:

• A. She uses humor to put the client at ease in a situation
• B. She restates what the client said in slightly different words
• C. She uses eye contact and maintains an open stance while the client is talking
• D. She provides personal information to show the client she can relate to him

Correct answer: C

Rationale: Active listening is a form of therapeutic communication that involves the nurse encouraging a client to express their thoughts and feelings. Maintaining eye contact and an open stance while the client is talking demonstrates active listening and shows the client that they are being heard and understood. Using humor (Choice A) may not always be appropriate or therapeutic in all situations. Restating what the client said (Choice B) is a technique known as paraphrasing and is also a form of active listening. Providing personal information (Choice D) can shift the focus from the client to the nurse, which is not the intention of active listening.

3. Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

• A. Air embolism.
• B. Cerebral hemorrhage.
• C. Expansion of the clot.
• D. Resolution of the clot.

Correct answer: B

Rationale: Cerebral hemorrhage is a significant complication associated with thrombolytic therapy in stroke treatment. Thrombolytic therapy aims to dissolve clots, but it increases the risk of bleeding, including cerebral hemorrhage. This risk is especially high when the therapy is administered quickly after a stroke, sometimes before confirming the type of stroke. Air embolism (Choice A) is not a common complication of thrombolytic therapy. Expansion of the clot (Choice C) and resolution of the clot (Choice D) are not expected outcomes of thrombolytic therapy; the therapy is specifically used to dissolve clots, not to expand or resolve them.

4. Which of the following white blood cells is the smallest and can be involved in humoral immunity?

• A. Lymphocyte
• B. Monocyte
• C. Basophil
• D. Erythrocyte

Correct answer: A

Rationale: The correct answer is 'Lymphocyte.' Lymphocytes are the smallest type of white blood cells and play a crucial role in humoral immunity by producing antibodies. Monocytes are actually the largest white blood cells and are involved in phagocytosis rather than humoral immunity. Basophils are a type of granulocyte involved in allergic reactions, and erythrocytes are red blood cells responsible for oxygen transport, not part of the immune system.

5. Which of the following is a local sign of infection?

• A. Swelling
• B. Rapid pulse
• C. Fever
• D. High white blood count

Correct answer: A

Rationale: A local sign of infection refers to symptoms that are specific to the area of infection. Swelling, heat, pain, and redness near the infected site are examples of local signs. In the context of infection, swelling occurs due to an accumulation of fluid and immune cells at the site of infection. Rapid pulse, fever, and high white blood count are more systemic responses to infection and not specific local signs. Rapid pulse can indicate systemic distress or sepsis, fever is a systemic response to infection, and high white blood count is a laboratory finding that suggests an immune response but is not a direct sign of infection at a specific site.

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