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. A male client is learning about testicular self-examination (TSE) from a nurse. Which statement should the nurse make to the client?

• A. 'A good time to examine the testicles is during or after you take a shower.'
• B. 'If you notice an enlarged testicle or a lump, you need to notify the physician.'
• C. 'The testicle is round and smooth. It feels firm and without lumps.'
• D. 'Perform a testicular exam monthly to detect early signs of testicular cancer.'

Correct answer: B

Rationale: The correct statement for the nurse to make to the client is 'If you notice an enlarged testicle or a lump, you need to notify the physician.' During a shower or bath is the best time to examine the testes because warm temperatures make the testes hang lower in the scrotum. The testes should feel round and smooth, without lumps. Self-examination should be performed monthly to detect any abnormalities early. The physician needs to be notified immediately if any abnormal findings are noticed. Choice A is incorrect because the best time for TSE is during or after a warm shower or bath, not just before. Choice C is incorrect as the testicle should feel round, smooth, and without lumps, not egg-shaped and lumpy. Choice D is incorrect as monthly self-examinations are recommended, not every 2 months.

3. Before administering the hepatitis B vaccine to a newborn infant, what should the nurse do?

• A. Request parental consent to administer the vaccine.
• B. Check the infant for jaundice.
• C. Check the infant's temperature.
• D. Obtain parental consent to administer the vaccine.

Correct answer: D

Rationale: Before administering the hepatitis B vaccine to a newborn infant, the nurse must obtain parental consent. Hepatitis B vaccine is typically given at birth, 1 month, and 6 months of age. Checking the infant for jaundice, checking the temperature, and requesting a hepatitis blood screen are unnecessary in this context. Parental consent is crucial for any medical intervention involving minors.

4. 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.

5. A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?

• A. Smiling
• B. Clenching the teeth
• C. Shrugging the shoulders against the nurse's resistance
• D. Identifying by taste a substance placed on the back of the tongue

Correct answer: C

Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.

Similar Questions