Nursing Elites

1. During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?

• A. Cranial nerve X
• B. Cranial nerve V
• C. Cranial nerve IX
• D. Cranial nerve XII

Correct answer: D

Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.

2. A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?

• A. vitiligo
• B. erythema
• C. cyanosis
• D. chloasma

Correct answer: D

Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes during pregnancy. Vitiligo is characterized by depigmented patches, erythema is redness of the skin due to increased blood flow, and cyanosis is a bluish discoloration due to poor circulation or lack of oxygen, none of which are typical skin-color variations during pregnancy. Therefore, in a pregnant client, the most likely normal skin-color variation to be displayed is chloasma.

3. The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?

• A. I'm worried that my child is not using two-word phrases yet.
• B. My child has recently taken a few steps but does not seem stable when standing.
• C. My child seems to have developed separation anxiety when I leave.
• D. I'm letting my child use a spoon to eat.

Correct answer: B

Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.

4. As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?

• A. builds towers with several blocks
• B. tries to color within the lines
• C. says "Mine!"? when playing with toys
• D. tries to jump rope

Correct answer: C

Rationale: For a 2-year-old child, saying 'Mine!' when playing with toys is an example of age-appropriate play. Toddlers at this age are possessive and asserting their sense of ownership. Building towers with blocks and trying to color within the lines involve more advanced motor skills and cognitive abilities that are typically not fully developed in a 2-year-old. Jumping rope requires coordination and balance beyond what a 2-year-old can usually achieve. Therefore, choices A, B, and D are not considered age-appropriate plays for a 2-year-old child.

5. If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?

• A. retrograde ejaculation
• B. decreased plasma testosterone
• C. hypertrophy of testicles
• D. state of euphoria

Correct answer: B

Rationale: In chronic renal failure, untreated, the client is at risk of developing decreased plasma testosterone. This condition leads to atrophy of the testicles and decreased spermatogenesis. Retrograde ejaculation is not a complication of chronic renal failure but can occur after transurethral resection of the prostate. The testicles atrophy in chronic renal failure; they do not hypertrophy. Additionally, chronic renal failure often leads to a state of depression, not euphoria.

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