Nursing Elites

1. A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?

• A. Assessing visual acuity
• B. Inspecting the eyelids for ptosis
• C. Assessing pupil constriction
• D. Assessing ocular movements

Correct answer: A

Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.

2. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask a client providing subjective data?

• A. Do you normally experience menstrual cramps with your periods?
• B. Do you smoke cigarettes?
• C. Are you currently dieting?
• D. Do you engage in strenuous exercise, such as jogging?

Correct answer: B

Rationale: The correct question the nurse should ask to identify risk factors associated with the use of an oral contraceptive is whether the client smokes cigarettes. Oral contraceptives are associated with an increased risk of thromboembolic phenomena, particularly when combined with other risk factors like smoking and a history of thrombosis. Other risk factors include hypertension, cerebrovascular disease, coronary artery disease, and postoperative thrombosis risk. Choices A, C, and D are not directly related to the increased risks associated with oral contraceptive use. Menstrual cramps, dieting, and strenuous exercise are not significant risk factors for thromboembolic events.

3. When preparing to listen to a client's breath sounds, what technique should a nurse use?

• A. Ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap.
• B. Listen to the right lung first, then the left lung, moving from top to bottom systematically.
• C. Ask the client to take deep breaths through the mouth.
• D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest.

Correct answer: D

Rationale: When preparing to listen to a client's breath sounds, a nurse should ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little more deeply than usual but to stop if feeling dizzy. The nurse should use the flat diaphragm end-piece of the stethoscope, holding it firmly on the chest wall. By using the diaphragm, the nurse can listen for at least one full respiration in each location, moving from side to side to compare sounds. This technique ensures a systematic and thorough assessment of lung sounds. Choice A is correct as it includes the proper positioning of the client and specifies the use of the diaphragm of the stethoscope. Choice B is incorrect as both lungs should be auscultated systematically, starting from the top and moving down. Choice C is incorrect as deep breaths, not shallow ones, are recommended for an accurate assessment of breath sounds.

4. The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should provide which response to the parents?

• A. That this is normal behavior for an adolescent
• B. That their daughter's behavior may be a part of adolescent development
• C. That this behavior could be a phase as the adolescent explores identity
• D. To restrict any social privileges until the behavior stops

Correct answer: A

Rationale: During adolescence, identity formation is a significant developmental task. Adolescents may appear self-centered, lazy, or irresponsible as they focus on themselves and explore their identity. Erikson describes this phase as identity formation versus role confusion. It is common for frustrated parents to perceive teenagers this way. The adolescent needs time to introspect and develop a sense of self. Suggesting that the behavior requires a child psychologist is premature and not supported by normal adolescent development. Blaming the behavior on parental spoiling is also inaccurate and unhelpful. Restricting social privileges can lead to resentment and rebellion, rather than addressing the root of the behavior.

5. During a health assessment, a nurse is assisting with gathering subjective data from a client and plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?

• A. Aunts, uncles, grandparents, and cousins
• B. Foster children and their parents
• C. Wife's children from a previous marriage
• D. Wife and wife's parents

Correct answer: B

Rationale: The correct answer is 'Aunts, uncles, grandparents, and cousins.' When gathering medical history from the client's extended family, it is essential to inquire about relatives beyond the nuclear family, such as aunts, uncles, grandparents, and cousins, as they share genetic and environmental influences. Choice C, 'Wife's children from a previous marriage,' pertains to stepchildren, not extended family members. Choice B, 'Foster children and their parents,' involves individuals who are not biologically related to the client's family. Choice D, 'Wife and wife's parents,' focuses solely on immediate family members and excludes the client's extended family members, which are crucial for a comprehensive health assessment.

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