Nursing Elites

1. A nurse is reviewing the findings of a physical examination documented in a client's record. Which piece of information does the nurse recognize as objective data?

• A. The client is allergic to strawberries
• B. The last menstrual period was 30 days ago
• C. The client takes acetaminophen (Tylenol) for headaches
• D. A 1-2-inch scar is present on the lower right portion of the abdomen

Correct answer: D

Rationale: Objective data in a physical examination are findings that the healthcare provider observes or measures directly. In this case, a 1 � 2-inch scar present on the lower right portion of the abdomen is a physical observation. Subjective data are based on what the client reports, such as allergies (Choice A), the date of the last menstrual period (Choice B), and self-reported medication use for headaches (Choice C). While these pieces of information are important for assessing the client's health, they are considered subjective data because they rely on the client's self-report rather than direct observation by the healthcare provider.

2. A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

• A. Constriction of the underlying blood vessels
• B. An increased amount of bilirubin in the blood
• C. Increased perfusion of the surrounding tissues
• D. Excess blood in the dilated superficial capillaries

Correct answer: D

Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.

3. When reviewing a client's medical notes to confirm pregnancy, a nurse should look for which finding to determine that pregnancy is confirmed?

• A. Amenorrhea
• B. Thinning of the cervix
• C. Palpable fetal movement
• D. Positive result on a home urine test for pregnancy

Correct answer: C

Rationale: To confirm pregnancy, the presence of palpable fetal movement is a positive indicator. Palpable fetal movement is a certain sign of pregnancy, known as a fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy as it is reported by the woman but is not confirmatory. Thinning of the cervix (Hegar sign) is a probable sign of pregnancy, which is not confirmatory. A positive result on a home urine test for pregnancy is also a probable indicator. However, a positive pregnancy test result can sometimes yield false-positive results due to various factors like medication, recent pregnancy, or errors in reading.

4. 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.

5. When educating an obese client about nutritional needs and weight loss, which of the following should not be included?

• A. knowledge of food and food products
• B. development of a positive mental attitude
• C. adequate exercise
• D. starting a fast weight-loss diet

Correct answer: D

Rationale: When educating an obese client about nutritional needs and weight loss, it is important to cover factors such as knowledge of food and food products, the development of a positive mental attitude, and the importance of adequate exercise. These aspects contribute to a holistic approach to weight management. However, recommending the client to start a fast weight-loss diet should not be included. Fast weight-loss diets can be harmful, leading to health risks, nutrient deficiencies, and unsustainable outcomes. It is crucial to advocate for gradual, sustainable weight loss strategies to ensure long-term success and overall well-being. Therefore, starting a fast weight-loss diet is the least appropriate option among the choices provided.

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