Nursing Elites

1. A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:

• A. Evisceration
• B. Hematoma
• C. Dehiscence
• D. Granulation

Correct answer: C

Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.

2. When teaching a Vietnamese patient who has been treated for pneumonia and needs to complete her antibiotic regimen at home, what is an important cultural component to consider?

• A. Cupping will help to pull toxins from the body
• B. Coining will help to release the wind or bad energy from the body
• C. Once symptoms disappear there is no longer an illness
• D. Most households consist of at least 3 generations

Correct answer: C

Rationale: The correct answer is 'Once symptoms disappear there is no longer an illness'. In Vietnamese culture, there is a belief that once symptoms go away, the illness is no longer present and does not require further treatment. This is crucial to understand when educating Vietnamese patients about completing their antibiotic regimen. Choices A and B (cupping and coining) are traditional Vietnamese healing practices that are not directly related to completing antibiotic therapy. Choice D, about households consisting of multiple generations, is not directly relevant to the completion of antibiotic treatment for pneumonia in this context.

3. Tommy R., your 68-year-old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy's ______________ in order to prevent him from falling again.

• A. bedside rails up at all times
• B. bed in the low position
• C. call bell within reach
• D. family members in the room at all times

Correct answer: C

Rationale: To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.

4. Which of the following may be a cultural barrier that impacts a healthcare provider's ability to provide care or education to the client?

• A. A healthcare provider offers educational materials to a client that are written at an 8th-grade reading level
• B. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics
• C. A healthcare provider uses pantomime to explain a procedure to a deaf client
• D. A Native American client requests a healing ritual before considering surgery

Correct answer: C

Rationale: Cultural barriers can impede communication, hindering a healthcare provider's ability to provide education or instructions about a client's care. In the context of cultural sensitivity, using pantomime to explain a procedure to a deaf client can be ineffective and inappropriate. This approach implies a lack of recognition of the importance of proper communication methods, such as sign language interpreters, which are crucial for effective communication with individuals who are deaf. Miscommunication is likely to occur if the client does not understand the gestures and actions of the healthcare provider. This scenario highlights the significance of understanding and respecting different cultural practices and communication needs to deliver optimal care and education. Choice A is incorrect because offering educational materials at an appropriate reading level demonstrates consideration for the client's literacy level, which can enhance understanding and compliance with medical instructions. Choice B is incorrect as incorporating a client's cultural practices, such as steaming, alongside prescribed treatments can be a part of culturally competent care. Choice D is incorrect as respecting a client's request for a healing ritual aligns with providing patient-centered care that acknowledges and integrates cultural beliefs and preferences.

5. Which of the following is a true statement about assessing blood pressure by palpation?

• A. Only the diastolic blood pressure can be assessed through palpation.
• B. The palpation technique is most useful for infants and small children.
• C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
• D. Only the systolic blood pressure can be assessed through palpation.

Correct answer: D

Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.

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