Nursing Elites

1. When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?

• A. Palpating the carotid artery in the upper third of the neck
• B. Palpating both arteries simultaneously to compare amplitude
• C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits
• D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery

Correct answer: C

Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.

2. 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.

3. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

4. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

• A. The client has a history of Type II diabetes.
• B. The client is on a continuous tube-feeding regimen.
• C. The client is on fluid restriction.
• D. The pharmacy has provided phenytoin in tablet form.

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

5. Which of the following are included in the Rights of Medication Administration? Select all that apply.

• A. Right dose, right time, right explanation, right client, right route
• B. Right dose, right time, right client, right route
• C. Right dose, right time, right client
• D. Right time, right explanation, right client

Correct answer: B

Rationale: The Rights of Medication Administration include the right client, right drug, right dose, right route, and right time. An additional right that is sometimes included is the right documentation. The correct answer includes the essential rights that must be ensured during medication administration. Choice A is incorrect as 'right explanation' is not part of the traditional Rights of Medication Administration. Choice B is incorrect as 'right explanation' is not included, and choice C is missing the right route. Choice D is incorrect as it lacks the right dose and right route.

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