Nursing Elites

1. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

2. The nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect to observe in this client?

• A. Weight loss
• B. Cold intolerance
• C. Bradycardia
• D. Dry skin

Correct answer: A

Rationale: Weight loss is a common finding in clients with hyperthyroidism due to increased metabolic activity. Hyperthyroidism leads to an overactive thyroid gland, which results in an increased metabolic rate and often leads to weight loss despite a normal or increased appetite. Cold intolerance (Choice B) is more commonly associated with hypothyroidism, where the body's processes slow down. Bradycardia (Choice C) is a slow heart rate, which is not typically seen in hyperthyroidism; rather, tachycardia or an increased heart rate is more common. Dry skin (Choice D) is also not a typical finding in hyperthyroidism, as the skin is more likely to be warm and moist due to increased metabolic activity.

3. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

• A. Determine if the expected outcomes were realistic
• B. Obtain current client data to compare with expected outcomes
• C. Modify the nursing interventions to achieve the client's goals
• D. Review related professional standards of care

Correct answer: B

Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.

4. During an abdominal assessment for an adult client, what is the correct sequence of steps?

• A. Inspect, Auscultate, Percuss, Palpate
• B. Palpate, Percuss, Inspect, Auscultate
• C. Auscultate, Inspect, Percuss, Palpate
• D. Percuss, Palpate, Inspect, Auscultate

Correct answer: A

Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.

5. Which statement made by a client indicates to the nurse that they may have a thought disorder?

• A. 'I'm so angry about this. Wait until my partner hears about this.'
• B. 'I'm a little confused. What time is it?'
• C. 'I can't find my missing shoes. Have you seen them?'
• D. 'I'm fine. It's my daughter who has the problem.'

Correct answer: C

Rationale: The statement 'I can't find my missing shoes. Have you seen them?' displays disorganized thinking or speech, which is characteristic of a thought disorder. The mention of 'missing shoes' in a context that does not make logical sense suggests a disturbance in thought processes. Choices A, B, and D do not demonstrate disorganized thinking typical of thought disorders. Option A reflects emotional expression, option B indicates mild confusion, and option D shows a redirection of focus to someone else's problem.

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