Nursing Elites

1. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:

• A. Referred pain
• B. Superficial pain
• C. Radiating pain
• D. Precipitating pain

Correct answer: C

Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.

2. Which of the following vital signs can be expected in a child that is afebrile?

• A. Rectal Temp of 100.9 degrees F.
• B. Oral Temp of 38 degrees C.
• C. Axillary Temp of 98.6 degrees F.
• D. All of the above are incorrect.

Correct answer: C

Rationale: The correct answer is the axillary temperature of 98.6 degrees F. Afebrile means without a fever, and an axillary temperature, which is taken in the armpit, is considered normal at 98.6 degrees F. Choice A is incorrect as a rectal temperature of 100.9 degrees F indicates a fever. Choice B is incorrect as an oral temperature of 38 degrees C is also indicative of a fever. Choice D is incorrect as not all options are wrong; only choices A and B are incorrect for an afebrile child.

3. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?

• A. Cataracts
• B. Glaucoma
• C. Astigmatism
• D. Presbyopia

Correct answer: D

Rationale: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.

4. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.

• A. Client has an actual health problem
• B. Client has a wellness diagnosis
• C. Collaborative health problem needs to be written
• D. Possible nursing diagnosis exists

Correct answer: B

Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.

5. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?

• A. "Are you of the Christian faith?"?
• B. "Do you want to see a medicine man?"?
• C. "How often do you seek help from medical providers?"?
• D. "What cultural or spiritual beliefs are important to you?"?

Correct answer: D

Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication. Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.

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