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 provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction?

• A. ''I should wear cool, light clothing in warm weather.''
• B. ''I need to wear a hat with a wide brim when I go outdoors.''
• C. ''I need to wear additional antiperspirant and deodorant in warm weather.''
• D. ''I should drink extra fluids during the summer.''

Correct answer: C

Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and decreased evaporative heat loss due to less sweating. The need for antiperspirants and deodorants is reduced in older adults. Therefore, the statement 'I need to wear additional antiperspirant and deodorant in warm weather' indicates a need for further instruction. Older adults should focus on wearing cool, light clothing in warm weather to prevent overheating, wearing a hat with a wide brim when outdoors to protect from the sun's rays, and staying hydrated by drinking extra fluids during the summer. These measures are more effective in preventing heatstroke in older adults compared to using additional antiperspirants and deodorants, which are not necessary.

3. The LPN is admitting a client to the unit, and the client has rapidly blinking eyes, a stuck-out tongue, and a distorted posture. Which of these medications is the client most likely taking?

• A. Clozapine
• B. Fluoxetine
• C. Ondansetron
• D. Haloperidol

Correct answer: D

Rationale: The correct answer is Haloperidol. Haloperidol is a first-generation antipsychotic that blocks dopamine receptors and is most likely to cause extrapyramidal symptoms (EPS), such as tardive dyskinesia. Symptoms of tardive dyskinesia include rapid blinking, mouth movements, sticking out the tongue, rapid body movements, and a distorted posture. Haloperidol is associated with a higher risk of EPS compared to other antipsychotic medications like Clozapine. Clozapine is known for having a lower risk of causing EPS. Fluoxetine is a selective serotonin reuptake inhibitor used for depression and anxiety, not typically associated with these movement disorder symptoms. Ondansetron is an antiemetic used to prevent nausea and vomiting, not linked to these extrapyramidal symptoms.

4. An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?

• A. The client has a low cardiac output.
• B. The client has a high cardiac output.
• C. The client has a normal cardiac output.
• D. The client will need a blood transfusion.

Correct answer: C

Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.

5. A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse provides which instruction?

• A. It is safe to try any type of complementary alternative therapy to relieve nausea
• B. The physician or nurse-midwife needs to provide a prescription for acupressure devices
• C. Devices that apply pressure alone are available over the counter
• D. Complementary alternative therapies should not be used during pregnancy

Correct answer: C

Rationale: The correct answer is 'Devices that apply pressure alone are available over the counter.' Acupressure over the Neiguan acupuncture point can be used as a complementary alternative therapy to relieve nausea during pregnancy. It can be performed with devices that apply pressure alone, which are available over the counter. Acupressure devices that apply electrical impulses over this point require a prescription. It is not safe to try any type of complementary alternative therapy during pregnancy, as some may be harmful to the mother and fetus. Therefore, the nurse should instruct the client about the availability of over-the-counter pressure devices for acupressure, which are generally safe to use.

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