Nursing Elites

1. During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?

• A. Documents the normal finding
• B. Checks for penile discharge, as this indicates infection
• C. Palpates for a mass in the scrotum, as wrinkling suggests the presence of one
• D. Obtains additional subjective data from the client, focusing on the scrotal abnormality

Correct answer: A

Rationale: The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.

2. A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?

• A. Ptosis
• B. Nystagmus
• C. Scleral icterus
• D. Exophthalmos

Correct answer: B

Rationale: When a nurse observes rapid, involuntary oscillating movements of the eyeball in a client, this is described as nystagmus. Nystagmus appears as a fine oscillating movement, most notable around the iris. It is important to assess for nystagmus when evaluating ocular muscle weakness. Mild nystagmus at extreme lateral gaze is considered normal; nystagmus in any other position is not. Ptosis refers to a drooping of the eyelid, not rapid eye movements. Scleral icterus is the yellowing of the sclera up to the cornea, indicating jaundice, not related to eye movements. Exophthalmos is a noticeable protrusion of the eyeball, typically seen in hyperthyroidism, not associated with rapid oscillating eye movements.

3. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?

• A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
• B. taking a cool shower and drinking a hot cup of tea
• C. watching TV nightly until midnight
• D. getting a back rub and drinking a glass of warm milk

Correct answer: D

Rationale: The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.

4. How should a client's neck be positioned for palpation of the thyroid?

• A. flexed toward the side being examined
• B. hyperextended directly backward
• C. flexed away from the side being examined
• D. flexed directly forward

Correct answer: A

Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.

5. A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?

• A. By checking the client's urine for blood
• B. By checking the client's stool for blood
• C. By checking the client's urine for a decrease in output
• D. By checking the client's bowel movements for diarrhea

Correct answer: B

Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

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