Nursing Elites

1. Which condition is associated with inadequate intake of vitamin C?

• A. rickets
• B. marasmus
• C. kwashiorkor
• D. scurvy

Correct answer: D

Rationale: Scurvy is indeed associated with inadequate intake of vitamin C. Vitamin C deficiency leads to scurvy, which is characterized by weakness, anemia, gum disease, and skin hemorrhages. Choices A, B, and C are incorrect because rickets is caused by vitamin D deficiency, marasmus is due to severe malnutrition leading to wasting, and kwashiorkor is a form of severe protein-energy malnutrition.

2. The nurse, assisting with data collection of the abdomen, inspects the client’s abdomen. Which assessment technique should the nurse perform next?

• A. Percussion
• B. Auscultation
• C. Light palpation
• D. Deep palpation

Correct answer: B

Rationale: The correct answer is auscultation. The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are normally performed in this order. However, in the abdominal examination, auscultation is performed after inspection and before palpation and percussion. This order is specific to the abdomen because palpation and percussion can increase peristalsis, leading to a false interpretation of bowel sounds. Therefore, auscultation is performed before palpation and percussion in abdominal assessments to ensure accurate bowel sound assessment. Percussion and palpation are performed after auscultation in abdominal assessments. Choices A, C, and D are incorrect as auscultation is the next assessment technique to perform after inspection in abdominal assessments, followed by palpation and percussion.

3. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

4. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?

• A. The young adult is sensitive to criticism.
• B. The young adult verbalizes unrealistic fears.
• C. The young adult verbalizes disappointment with life.
• D. The young adult verbalizes satisfaction with friendships.

Correct answer: D

Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.

5. A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?

• A. Ptosis
• B. Nystagmus
• C. Scleral icterus
• D. Exophthalmos

Correct answer: B

Rationale: When a nurse observes rapid, involuntary oscillating movements of the eyeball in a client, this is described as nystagmus. Nystagmus appears as a fine oscillating movement, most notable around the iris. It is important to assess for nystagmus when evaluating ocular muscle weakness. Mild nystagmus at extreme lateral gaze is considered normal; nystagmus in any other position is not. Ptosis refers to a drooping of the eyelid, not rapid eye movements. Scleral icterus is the yellowing of the sclera up to the cornea, indicating jaundice, not related to eye movements. Exophthalmos is a noticeable protrusion of the eyeball, typically seen in hyperthyroidism, not associated with rapid oscillating eye movements.

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