Nursing Elites

1. When inspecting the ears for cerumen impaction, the nurse checks for which finding?

• A. Redness and swelling of the tympanic membrane
• B. An external auditory canal that is longer than normal
• C. The presence of edema in the external auditory canal
• D. A yellowish or brownish waxy material in the external auditory canal

Correct answer: D

Rationale: When inspecting the ears for cerumen impaction, the nurse should look for a yellowish or brownish waxy material in the external auditory canal. Cerumen, also known as ear wax, is a secretion that can become impacted due to various reasons. It is produced by the vestigial apocrine sweat glands in the external ear canal. Cerumen may partially obscure the eardrum or totally occlude the ear canal. The other options, redness and swelling of the tympanic membrane, an external auditory canal that is longer than normal, and the presence of edema in the external auditory canal, are not indicative findings of cerumen impaction.

2. The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?

• A. Inform the staff on the other floor of any unresolved issues with the client.
• B. Ask the charge nurse if overtime would be permitted to complete the client's transfer to the other floor.
• C. Ask the new nurse to take care of the transfer since the client's medical record has all of the information, and a report should not be needed.
• D. Complete the transfer paperwork before the client is transferred.

Correct answer: C

Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.

3. 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.

4. A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?

• A. Primary
• B. Secondary
• C. Tertiary
• D. Health promotion

Correct answer: A

Rationale: Primary prevention involves activities that promote wellness or prevent illness or injury. Educating parents about safety measures in the home aims to prevent injuries, making it a primary prevention strategy. Secondary prevention focuses on early detection and intervention in diseases or injuries. Tertiary prevention involves reducing disability and promoting optimal functioning in relation to a disease or injury. Health promotion encompasses activities that enhance a client's overall health and well-being. In this scenario, educating parents about safety in the home falls under primary prevention as it aims to prevent injuries before they occur.

5. A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing which disorder?

• A. Venous insufficiency
• B. Intermittent claudication
• C. Sore muscles from overexertion
• D. Muscle cramps related to musculoskeletal problems

Correct answer: B

Rationale: Leg pain characteristic of peripheral artery disease is known as intermittent claudication. The client can walk only a certain distance before cramping, burning, muscle discomfort, or pain forces them to stop, with the pain subsiding after rest. The pain is reproducible, and as the disease progresses, the client can walk shorter distances before the pain recurs. Ultimately, pain may even occur at rest. Venous insufficiency (Choice A) involves impaired blood flow in the veins, leading to swelling and skin changes but not typically pain associated with exercise. Sore muscles from overexertion (Choice C) and muscle cramps related to musculoskeletal problems (Choice D) do not present with the characteristic pattern of pain associated with peripheral artery disease.

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