Nursing Elites

1. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

2. When providing oral care for an unconscious client, which of the following actions should the nurse take?

• A. Place the client in a lateral position with the head turned to the side before beginning the procedure.
• B. Insert a suction catheter before brushing the teeth.
• C. Use a soft-bristled toothbrush only with water.
• D. Brush the client's teeth while they are in a supine position.

Correct answer: A

Rationale: When providing oral care for an unconscious client, it is essential to place them in a lateral position with the head turned to the side before beginning the procedure. This positioning helps prevent aspiration by allowing fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Inserting a suction catheter before brushing the teeth (Choice B) is not recommended as it can cause discomfort and increase the risk of oral tissue injury. Using a soft-bristled toothbrush only with water (Choice C) is not sufficient for effective oral care as toothpaste helps in removing plaque and bacteria. Brushing the client's teeth while they are in a supine position (Choice D) is not safe as it increases the risk of aspiration since fluids can easily enter the airway in this position.

3. A 3-year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?

• A. Allergies
• B. Scabies
• C. Regression
• D. Pinworms

Correct answer: D

Rationale: The correct answer is D, Pinworms. Pinworms are a common cause of itching around the anal area, especially at night, in young children. Scratching the bottom and bedwetting can be indicative of a pinworm infection. Allergies (Choice A) are less likely given the symptoms described. Scabies (Choice B) may cause itching but is less common in causing bedwetting. Regression (Choice C) is not a common cause of these specific symptoms in a 3-year-old child.

4. While auscultating a client's abdomen, a nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following?

• A. Gallop
• B. Bruit
• C. Thrill
• D. Murmur

Correct answer: B

Rationale: The correct answer is B: Bruit. A bruit is a blowing sound indicating turbulent blood flow, often heard over the aorta. Choices A, C, and D are incorrect. A gallop is a cardiac sound resembling the sound of a galloping horse. A thrill is a vibration felt on palpation, and a murmur is a swooshing or whooshing sound heard during auscultation of the heart or blood vessels. In this scenario, the blowing sound over the aorta specifically indicates a bruit, which signifies turbulent blood flow and should be further assessed by the healthcare provider.

5. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?

• A. Chamomile
• B. Ginseng
• C. Ginger
• D. Echinacea

Correct answer: A

Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.

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