Nursing Elites

1. While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?

• A. Document the finding
• B. Palpate the area for a mass
• C. Notify the healthcare provider
• D. Percuss the abdomen to check for tympany

Correct answer: C

Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.

2. The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?

• A. ''I should eat five or six small meals a day rather than three full meals.''
• B. ''I need to be sure not to drink liquids with my meals.''
• C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
• D. ''I need to avoid eating fried or greasy foods.''

Correct answer: B

Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.

3. A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:

• A. climacteric
• B. menopause
• C. perimenopause
• D. postmenopause

Correct answer: C

Rationale: Perimenopause refers to a period during which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause typically lasts around five years. Climacteric is a term that describes the period when physiologic changes result in the cessation of a woman's reproductive ability and decreased sexual activity. This term applies to both genders. Menopause is the time when menstruation permanently stops. Postmenopause refers to the period after menopausal changes are complete. In this scenario, the woman's irregular menses indicate she is likely in the perimenopausal stage, experiencing hormonal fluctuations and changes.

4. When discussing birth control methods with a client, what major factor should a nurse focus on to provide the motivation needed for consistent implementation of a birth control method?

• A. Personal preference
• B. Work and home schedules
• C. Family planning goals
• D. Desire to have children in the future

Correct answer: A

Rationale: When discussing birth control methods with a client, a nurse should focus on the client's personal preference as a major factor that will provide the motivation needed for consistent implementation of a birth control method. Personal preference plays a key role in ensuring that the chosen method aligns with the client's lifestyle and values, increasing the likelihood of adherence. While work and home schedules, family planning goals, and the desire to have children in the future can influence the choice of birth control method, they are not the primary motivating factors for consistent implementation. Personal preference is crucial as it empowers the client to select a method that suits their individual needs and preferences, ultimately leading to better compliance and effectiveness.

5. Which of the following vaccines is not part of the regular schedule of immunizations for children?

• A. DTaP
• B. MMR
• C. Hib
• D. hepatitis A

Correct answer: D

Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.

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