Nursing Elites

1. A patient is seen in the clinic for reports of "fainting episodes that started last week."? How would the nurse proceed with the examination?

• A. Blood pressure readings are taken in both arms and thighs.
• B. The patient is assisted to a lying position, and their blood pressure is taken.
• C. The patient's blood pressure is recorded in lying, sitting, and standing positions.
• D. The patient's blood pressure is recorded in lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.

Correct answer: C

Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure. Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.

2. The healthcare professional notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

• A. Yield a falsely low blood pressure
• B. Yield a falsely high blood pressure
• C. Be the same, regardless of cuff size
• D. Vary as a result of the technique of the person performing the assessment

Correct answer: B

Rationale: Using a cuff that is too narrow for an obese patient would likely yield a falsely high blood pressure reading. This occurs because the standard cuff is too small for the arm's circumference, requiring more pressure to compress the artery. A tight cuff can lead to inaccurate and elevated blood pressure readings. Choices A, C, and D are incorrect because using an improperly sized cuff would not yield a falsely low blood pressure, the blood pressure reading does vary with cuff size, and the technique of the person performing the assessment is not the primary factor affecting the reading in this situation.

3. A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak "perfect English."? What is this woman likely experiencing?

• A. Culture shock
• B. Cultural taboos
• C. Cultural unfamiliarity
• D. Culture disorientation

Correct answer: A

Rationale: The woman in the scenario is likely experiencing culture shock. Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group due to sudden strangeness, unfamiliarity, and incompatibility with the individual's perceptions and expectations. In this case, the woman's feelings of shyness and retreating due to not feeling confident in speaking 'perfect English' align with symptoms of culture shock. The other choices are incorrect: Cultural taboos refer to behaviors or actions that are prohibited within a particular culture; cultural unfamiliarity suggests a lack of knowledge about a specific culture, which is not the case here; and culture disorientation is not a commonly used term in cultural psychology, making it an incorrect option.

4. How does the procedure for taking a pulse rate on an infant differ from an adult?

• A. Pulse rates are taken on infants using a different method.
• B. The apical pulse method is used on infants.
• C. Pulse rates on infants are taken with a sphygmomanometer.
• D. Pulse rates on infants are taken apically in the third intercostal space.

Correct answer: B

Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately. Choices A, C, and D are incorrect. Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method. Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates. Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.

5. Which of the following vital signs can be expected in a child that is afebrile?

• A. Rectal Temp of 100.9 degrees F.
• B. Oral Temp of 38 degrees C.
• C. Axillary Temp of 98.6 degrees F.
• D. All of the above are incorrect.

Correct answer: C

Rationale: The correct answer is the axillary temperature of 98.6 degrees F. Afebrile means without a fever, and an axillary temperature, which is taken in the armpit, is considered normal at 98.6 degrees F. Choice A is incorrect as a rectal temperature of 100.9 degrees F indicates a fever. Choice B is incorrect as an oral temperature of 38 degrees C is also indicative of a fever. Choice D is incorrect as not all options are wrong; only choices A and B are incorrect for an afebrile child.

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