Nursing Elites

1. 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.

2. A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. What should be the nurse's next action?

• A. Document the client's concern in the medical record.
• B. Report the client's concern to the health care provider.
• C. Tell the client that sexual dysfunction is not a normal age-related change.
• D. Ask the client about medications he is taking.

Correct answer: D

Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. It is crucial to assess the medications the client is taking as they could be contributing to the reported sexual dysfunction. While documenting the concern and informing the healthcare provider are important steps, the immediate priority is to gather information on the medications that could be impacting the client's sexual function. Therefore, the nurse's next action should be to ask the client about the medications he is taking.

3. The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?

• A. McGill Pain Scale
• B. FLACC Pain Scale
• C. CRIES Pain Scale
• D. Wong-Baker Pain Scale

Correct answer: D

Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.

4. A nurse preparing to assist with data collection of the abdomen asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?

• A. Dullness
• B. Tympany
• C. Borborygmus
• D. Hyperresonance

Correct answer: B

Rationale: The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is in a supine position. Dullness is usually heard over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus, which refers to hyperperistalsis, is typically heard on auscultation, not percussion. Hyperresonance is present with gaseous distention, not the typical finding when percussing all four quadrants of the abdomen.

5. Mr. H. is upset about being in the hospital for another day due to the high cost. The rights he is likely to demand include all of the following except:

• A. the right to examine and question the bill
• B. the right to reasonable response to requests
• C. the right to refuse treatment
• D. the right to confidentiality

Correct answer: D

Rationale: Confidentiality is the maintenance of privacy of information. The question does not suggest that confidentiality has been breached. In this scenario, Mr. H. is concerned about the cost and the length of his stay, which relates to his rights regarding billing, treatment, and response to requests. The right to confidentiality, though important, is not directly related to his current situation of being upset about the high cost and extended stay. Mr. H. is more likely to demand the right to examine and question the bill to understand the charges, the right to reasonable response to requests regarding his care and stay, and the right to refuse treatment if he wishes. Therefore, the correct answer is the right to confidentiality, as it is not a primary concern in this context.

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