Nursing Elites

1. A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client's chest?

• A. Second left interspace
• B. Second right interspace
• C. Left lower sternal border
• D. Fifth left interspace at the midclavicular line

Correct answer: D

Rationale: The correct placement for auscultating the apical heart rate in the area of the mitral valve is the fifth left interspace at the midclavicular line. Placing the stethoscope in the second left interspace would be to listen to the pulmonic valve, the second right interspace is for the aortic valve, and the left lower sternal border is for the tricuspid valve.

2. The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?

• A. She prefers crawling over walking and makes no attempt to walk.
• B. She seems distressed by new adults.
• C. She does not respond to her own name.
• D. She only babbles "mama"? and "dada."?

Correct answer: C

Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.

3. An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?

• A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
• B. Checking the amniotic fluid for intrauterine infection
• C. Determination of fetal lung maturity
• D. Checking the fetal cells for chromosomal abnormalities

Correct answer: C

Rationale: The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.

4. When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:

• A. "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes."?
• B. "If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age."?
• C. "When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch."?
• D. "You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time."?

Correct answer: A

Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.

5. A nurse preparing to examine a client’s eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?

• A. Near vision
• B. Color vision
• C. Distant vision
• D. Peripheral vision

Correct answer: D

Rationale: The correct answer is D: Peripheral vision. The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the nurse’s, assuming that the nurse’s vision is normal. During the test, the nurse positions themselves at eye level with the client, about 2 feet away, and directs the client to cover one eye with an opaque card. The nurse covers the eye opposite the client’s covered one and slowly moves a target (like a pencil) from the periphery in several directions. The client is asked to indicate when they see the target, which should coincide with when the nurse sees it. Near vision is tested using a handheld vision screener with various sizes of print, color vision with the Ishihara test, and distant vision with a Snellen chart. Therefore, choices A, B, and C are incorrect as they do not measure peripheral vision, which is the focus of the confrontation test.

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