Nursing Elites

1. A healthcare professional is reviewing the health care record of a client who has just undergone an examination of the internal genitalia. Which documented finding indicates an abnormality?

• A. The cervix is pink.
• B. The cervix is midline.
• C. The cervix is about 1 inch in diameter.
• D. Clear secretions with a foul odor are noted on the cervix.

Correct answer: D

Rationale: The correct answer is 'Clear secretions with a foul odor are noted on the cervix.' Normally, the cervix is pink, midline, and about 1 inch in diameter. Depending on the day of the menstrual cycle, secretions may vary. However, they should always be odorless and nonirritating. Secretions with a foul odor are indicative of an infection, making this finding abnormal. Choices A, B, and C describe normal cervix characteristics, so they do not indicate an abnormality in this scenario.

2. A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

• A. Headache
• B. Neck trauma
• C. Sinus infection
• D. Muscle spasms

Correct answer: B

Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.

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. Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.

• A. plug the patient to the ECG Monitor
• B. Administer the medication over at least 5 minutes.
• C. Monitor respirations during administration.
• D. Monitor the client's pulse for 1 minute prior to administration.

Correct answer: D

Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client's pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.

5. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

• A. Confirm the medical diagnosis.
• B. Make accurate nursing diagnoses.
• C. Identify any hereditary traits related to the epilepsy.
• D. Determine what the client believes has caused the epilepsy.

Correct answer: D

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

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