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. When transferring a client with hemiparesis from a bed to a wheelchair, which safety measure should be implemented?

• A. Standing the client and walking them to the wheelchair
• B. Moving the wheelchair close to the client's bed and standing and pivoting the client on their unaffected extremity to the wheelchair
• C. Moving the wheelchair close to the client's bed and standing and pivoting the client on their affected extremity to the wheelchair
• D. Having the client stand and push their body to the wheelchair

Correct answer: C

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure is to move the wheelchair close to the client's bed and have the client stand and pivot on their unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls or injuries. Choice A is incorrect as it suggests walking the client, which may not be safe or feasible. Choice C is incorrect because pivoting on the affected extremity can increase the risk of injury. Choice D is incorrect as it does not consider the client's limitations and safety needs, as it involves pushing their body which may not be possible with hemiparesis.

3. When a 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy, what should the nurse do first when interviewing the client?

• A. Assess the client's knowledge of available birth control methods.
• B. Inform the client that birth control methods can be discussed without the client's boyfriend present.
• C. Tell the client that for her age and lifestyle, birth control pills would be one of the methods of contraception.
• D. Give the client written material about various birth control methods and ask her to read them and to call if she has any questions.

Correct answer: A

Rationale: When a client seeks information about birth control, it is essential for the nurse to first assess the client's existing knowledge on the subject. This enables the nurse to provide tailored information that complements what the client already knows, facilitating better understanding and decision-making. Providing written material is a helpful educational tool but should not be the first intervention. Offering specific advice on birth control methods based on age and lifestyle limits the client's autonomy and decision-making process. Mentioning the client's boyfriend as a requirement for discussing birth control is inappropriate and nontherapeutic, as the client should be able to seek information independently.

4. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

• A. Risk for Self-Harm
• B. Body Image Disturbance
• C. Ineffective Role Performance
• D. Powerlessness

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and feeling incomplete due to infertility, which aligns with Body Image Disturbance. The statement does not directly indicate a risk for self-harm, so 'Risk for Self-Harm' is not the correct choice. 'Ineffective Role Performance' is not the best option as it does not address the client's primary concern regarding self-image. While 'Powerlessness' could be appropriate if the client expressed feelings of powerlessness related to infertility, it is not the most suitable diagnosis based on the given statement.

5. When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?

• A. That the cervix appears violet
• B. That cervical softening is present
• C. A positive sign of pregnancy
• D. A thinning of the cervix

Correct answer: A

Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one. Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.

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