Nursing Elites

1. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?

• A. Take off shoes while in the house and wear only socks
• B. Limit activities to the lower level of the home
• C. Keep a lamp near the door of every room
• D. Install non-slip pads in the shower or bathtub

Correct answer: D

Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.

2. To properly read a meniscus,

• A. hold the measuring device at eye level and read the bottom of the curve of the liquid level
• B. hold the measuring device at eye level and read the top of the curve of the liquid level where the liquid adheres to the walls of the container.
• C. hold the measuring device at table level and, looking down into the measuring device, read the bottom of the curve of the liquid level.
• D. hold the measuring device at table level and, looking down into the measuring device, read the top of the curve of the liquid level.

Correct answer: A

Rationale: To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface. Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements. Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.

3. The healthcare professional is preparing to auscultate the abdomen. How should they proceed?

• A. Warm the endpiece of the stethoscope by rubbing it between their hands.
• B. Ensure the patient is adequately covered and comfortable during the examination.
• C. Ensure that the diaphragm side of the stethoscope is in use.
• D. Check the room temperature and offer blankets to the patient if needed.

Correct answer: D

Rationale: When preparing to auscultate the abdomen, it is important to ensure the patient's comfort. The room should be warm to prevent shivering, which can interfere with sound clarity. Offering blankets to the patient if they feel cold helps maintain their comfort during the examination. The endpiece of the stethoscope should be warmed by rubbing it between the examiner's hands, not by placing it in warm water. It is important to use the diaphragm, not the bell, of the stethoscope to auscultate for bowel sounds. Therefore, choice D is the correct answer, as it addresses the patient's comfort and the room temperature, which are essential for a successful abdominal auscultation.

4. The student observes a patient with no breathing problems. Which action by the student indicates a need to review respiratory assessment skills?

• A. The student starts at the apices of the lungs and moves to the bases.
• B. The student compares breath sounds from side to side, avoiding bony areas.
• C. The student places the stethoscope over the posterior chest and listens during expiration.
• D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

Correct answer: C

Rationale: The correct answer is C. Listening only during inspiration instead of both inspiration and expiration indicates a need for a review of respiratory assessment skills. During chest auscultation, it is essential to listen to at least one cycle of inspiration and expiration at each placement of the stethoscope. Instructing the patient to breathe slowly and a little deeper than normal through the mouth is a correct practice during auscultation. The correct sequence for lung auscultation is from the apices to the bases, comparing breath sounds bilaterally, avoiding bony areas. It is crucial to place the stethoscope over lung tissue rather than bony prominences to accurately assess lung sounds.

5. Madge is a 91-year-old nursing home resident with a history of dementia and atrial fibrillation who has been admitted to the hospital for treatment of pneumonia. As you are performing her bed bath, you note bruising around her breasts and genital area. What potential issue should be of major concern in Madge's situation?

• A. Idiopathic thrombocytopenic purpura (ITP)
• B. Embolic stroke
• C. Sexual abuse
• D. Nursing home-acquired pneumonia (NHAP)

Correct answer: C

Rationale: Bruising around the breasts and genitals should trigger concern for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on behalf of vulnerable populations, such as the elderly. According to the National Center on Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. In this scenario, given Madge's age, history of dementia, and the presence of unexplained bruising in sensitive areas, sexual abuse must be considered as a major concern. Idiopathic thrombocytopenic purpura (ITP) is a platelet disorder that presents with excessive bruising and bleeding, but it is less likely in this case as the bruising pattern is suggestive of a different cause. Embolic stroke is a neurological condition that typically presents with sudden onset neurological deficits and is not related to the observed bruising. Nursing home-acquired pneumonia (NHAP) is a common issue in elderly residents but would not manifest as bruising in specific areas like the breasts and genitals.

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