Nursing Elites

1. A nurse is preparing to assist the healthcare provider in performing an internal gynecological examination of a client. In which position does the nurse place the client for this examination?

• A. Prone
• B. Left side-lying
• C. Sims
• D. Lithotomy

Correct answer: D

Rationale: An internal gynecological examination is performed with the client in the lithotomy position. In this position, the client is supine, with the feet in stirrups, the knees apart, and the buttocks at the end of the examining table. The client is draped so that only the vulva is exposed. The lithotomy position provides optimal access for the healthcare provider to perform the examination effectively. The prone position refers to lying on the stomach, which is not suitable for a gynecological exam. The Sims position is a left side-lying position primarily used for administering enemas, not for gynecological examinations.

2. A healthcare professional reviewing the health care record of a client notes documentation of grade 4 muscle strength. The healthcare professional understands that this indicates:

• A. Full ROM with gravity
• B. Full ROM against gravity with full resistance
• C. Full ROM with gravity eliminated (passive motion)
• D. Full ROM against gravity with some resistance

Correct answer: D

Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction. Therefore, the correct answer is 'Full ROM against gravity with some resistance.' Choices A, B, and C are incorrect as they do not match the description of muscle strength associated with a grade of 4.

3. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

• A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
• B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
• C. The organ procurement organization makes the decision regarding which organs to harvest.
• D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.

Correct answer: A

Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.

4. A home health care nurse is visiting a male African American client who was recently discharged from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications?

• A. The client's grandson
• B. The client's mother
• C. The client's father
• D. The client's son

Correct answer: B

Rationale: In the African American family structure, the woman, especially the mother, often plays a central role in healthcare decisions and maintaining family health. It is essential for the nurse to involve the client's mother in teaching him about his prescribed medications as she may be responsible for his care and treatment decisions. While other family members may also be involved, the African American family is often matrifocal, emphasizing the importance of the mother's role. Therefore, it is crucial for the nurse to ensure the client's mother is present during medication teaching. Choices A, C, and D are incorrect as they do not align with the traditional African American family structure and the role of women in healthcare decisions.

5. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?

• A. Firm pressure
• B. Pain behind the eyes
• C. Pain during palpation
• D. Pressure producing an acute headache

Correct answer: A

Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.

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