Nursing Elites

1. A nurse is trying to motivate a client toward more effective management of a therapeutic regimen. Which of the following actions by the nurse is most likely to be effective in increasing the client's motivation?

• A. determining if the client has any family or friends living nearby
• B. developing a concise discharge plan and reviewing it with the client
• C. teaching the client about the disorder at the client's level of understanding
• D. making a referral to an area agency for client follow-up

Correct answer: C

Rationale: To effectively motivate the client, it is important to educate them about the disorder at their level of understanding. This helps the client comprehend the importance of the therapeutic regimen and empowers them to actively participate in their treatment. Choice A, determining if the client has any family or friends living nearby, may provide social support but is less likely to directly impact the client's motivation compared to educating them about their condition. Developing a concise discharge plan, as in choice B, is crucial for continuity of care but may not directly enhance the client's motivation as effectively as providing education tailored to their level of understanding. Making a referral for follow-up, as in choice D, is important for ongoing care but may not have the same immediate impact on the client's motivation as educating them about their condition.

2. The client should include all of the following in teaching an obese client about nutritional needs and weight loss except:

• 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 crucial to emphasize a holistic approach that involves understanding food and food products, fostering a positive mental attitude, and incorporating adequate exercise. Initiating a fast weight-loss diet is not advisable due to potential health risks and lack of long-term sustainability. Therefore, this option stands out as the exception and should not be part of the client's learning. Choices A, B, and C are essential components of a healthy weight-loss plan and should be included in the client's education.

3. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?

• A. Iris
• B. Cornea
• C. Optic disc
• D. Conjunctiva

Correct answer: C

Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.

4. The nurse, assisting with data collection of the abdomen, inspects the client’s abdomen. Which assessment technique should the nurse perform next?

• A. Percussion
• B. Auscultation
• C. Light palpation
• D. Deep palpation

Correct answer: B

Rationale: The correct answer is auscultation. The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are normally performed in this order. However, in the abdominal examination, auscultation is performed after inspection and before palpation and percussion. This order is specific to the abdomen because palpation and percussion can increase peristalsis, leading to a false interpretation of bowel sounds. Therefore, auscultation is performed before palpation and percussion in abdominal assessments to ensure accurate bowel sound assessment. Percussion and palpation are performed after auscultation in abdominal assessments. Choices A, C, and D are incorrect as auscultation is the next assessment technique to perform after inspection in abdominal assessments, followed by palpation and percussion.

5. How should a nurse listen to the breath sounds of a client?

• A. Ask the client to lie prone.
• B. Ask the client to breathe in and out through the nose.
• C. Hold the bell of the stethoscope lightly against the chest.
• D. Listen for at least one full respiration in each location on the chest.

Correct answer: D

Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.

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