Nursing Elites

1. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?

• A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
• B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
• C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
• D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

Correct answer: C

Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.

2. When discussing the child's wishes for future care, it is important for the nurse to first identify what the child knows about the disease and his prognosis. Factors such as the perceived severity of the illness will be significant in planning for end-of-life care. If the child does not understand the disease process or prognosis, the plan of care would not be effective or realistic. In addition, asking a child about desired interventions in the event of cardiac or respiratory arrest would not be an appropriate initial area of questioning. If the child does not understand the disease process, these questions may seem frightening or threatening. While exploring the child's belief about death would be important, it would not be the initial area of discussion and should be guided by the child rather than the nurse.

• A. What the child knows about the disease and his prognosis.
• B. How the child would like to handle the plan of care.
• C. What interventions the child would like in the event of cardiac or respiratory arrest.
• D. What the child believes about death.

Correct answer: A

Rationale: When discussing the child's wishes for future care, it is essential to first determine what the child understands about the disease and his prognosis. This information is crucial for planning appropriate end-of-life care. If the child lacks comprehension of the illness and its prognosis, any care plan discussed would be ineffective and unrealistic. Inquiring about desired interventions during cardiac or respiratory arrest is not the initial step, as it may cause distress if the child lacks understanding. While exploring the child's beliefs about death is significant, it should not be the primary focus initially and should be approached based on the child's readiness, not the nurse's agenda. Therefore, the correct first step is to assess what the child knows about the disease and his prognosis.

3. A nurse suspects a patient is developing Bell's Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?

• A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
• B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
• C. Test the sensation of the facial muscles and sensation of the back of the tongue.
• D. Test the sensation of the facial muscles and sensation of the front of the tongue.

Correct answer: B

Rationale: The facial nerve (VII) is responsible for motor function to the face and sensory function to the anterior two-thirds of the tongue. Therefore, to appropriately test the function of cranial nerve VII, the most appropriate testing procedures involve assessing the taste sensation over the front of the tongue (sensory) and activation of the facial muscles (motor). Option B, 'Test the taste sensation over the front of the tongue and activation of the facial muscles,' is the correct answer. Choices A, C, and D are incorrect because they do not involve the correct combination of sensory testing over the front of the tongue and motor activation of the facial muscles, which are key functions associated with cranial nerve VII.

4. Which of the following is likely to increase the risk of sexually transmitted disease?

• A. alcohol use
• B. certain types of sexual practices
• C. oral contraception use
• D. all of the above

Correct answer: D

Rationale: All of the above factors are likely to increase the risk of sexually transmitted diseases (STDs). Alcohol use can impair judgment, leading to risky sexual behavior. Certain types of sexual practices, especially unprotected sex or multiple partners, increase the likelihood of contracting STDs. While oral contraception use does not directly increase the risk of STDs, it does not protect against them either. Therefore, all the choices (alcohol use, certain types of sexual practices, and oral contraception use) can contribute to an increased risk of contracting STDs.

5. A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?

• A. "I became dizzy when I stood up."?
• B. "I was nauseated and began vomiting."?
• C. "The pain started in my chest and stopped after I sat down."?
• D. "The pain began with a migraine and progressed to numbness in my left arm."?

Correct answer: B

Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.

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