Nursing Elites

1. A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at the time of admission?

• A. Place a padded tongue depressor at the head of the bed.
• B. Pad the bed with blankets.
• C. Inform the client about the importance of wearing a medical identification tag.
• D. Teach the client about seizures.

Correct answer: B

Rationale: The most essential measure when admitting a client who had a seizure is to pad the bed with blankets (Option B). This is crucial to prevent injury in case of another seizure. Placing a padded tongue depressor at the head of the bed (Option A) is incorrect as current nursing guidelines advise against putting anything in the client's mouth during a seizure. Informing the client about wearing a medical identification tag (Option C) and teaching the client about seizures (Option D) are important but are more relevant once the cause of the seizure is known. It's crucial to remember that not all seizures are classified as epilepsy.

2. A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?

• A. Bending the leg at the knee
• B. Turning the foot inward and outward
• C. Moving the leg in a circle
• D. Moving the leg forward and up

Correct answer: C

Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.

3. The student observes a patient with no breathing problems. Which action by the student indicates a need to review respiratory assessment skills?

• A. The student starts at the apices of the lungs and moves to the bases.
• B. The student compares breath sounds from side to side, avoiding bony areas.
• C. The student places the stethoscope over the posterior chest and listens during expiration.
• D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

Correct answer: C

Rationale: The correct answer is C. Listening only during inspiration instead of both inspiration and expiration indicates a need for a review of respiratory assessment skills. During chest auscultation, it is essential to listen to at least one cycle of inspiration and expiration at each placement of the stethoscope. Instructing the patient to breathe slowly and a little deeper than normal through the mouth is a correct practice during auscultation. The correct sequence for lung auscultation is from the apices to the bases, comparing breath sounds bilaterally, avoiding bony areas. It is crucial to place the stethoscope over lung tissue rather than bony prominences to accurately assess lung sounds.

4. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?

• A. Trying prayer before seeking medical help
• B. Believing that illness is a punishment of sin
• C. Refusing to accept blood products as part of treatment
• D. Stating that a child's birth defect is the result of the parents' sins

Correct answer: C

Rationale: The concept of a cultural taboo involves practices that are forbidden or avoided within a particular culture. Refusing to accept blood products as part of treatment is a clear example of a cultural taboo, as some cultures or religions prohibit the use of blood products for medical purposes. This practice is deeply rooted in cultural beliefs and traditions. The other choices provided do not directly relate to cultural taboos. Trying prayer before seeking medical help, believing illness is a punishment of sin, and stating that a child's birth defect is the result of parents' sins are beliefs or actions based on religious or personal beliefs, but they do not specifically represent cultural taboos.

5. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment?

• A. "Not recognized as valuable by most health care providers."?
• B. "Usually ineffective and may delay more effective treatment."?
• C. "Always less expensive than biomedical alternatives."?
• D. "Influenced by the accessibility of over-the-counter medicines."?

Correct answer: D

Rationale: After a symptom is identified, the first effort at treatment is often self-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments, such as over-the-counter medications, are effective. Self-treatment is not always less expensive. Choice A is incorrect as health care providers are recognizing the value of self-treatment. Choice B is incorrect because self-treatment can be effective in many cases. Choice C is incorrect as self-treatment is not always less expensive; it depends on the specific treatment being used.

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