Nursing Elites

1. Which of the following is an example of an extended care facility?

• A. Home health agency
• B. Suicide prevention center
• C. State-owned psychiatric hospital
• D. Nursing facility

Correct answer: D

Rationale: An extended care facility typically provides long-term care for individuals who require continuous assistance with activities of daily living. A nursing facility fits this description as it offers skilled nursing care and assistance with daily activities. Choices A, B, and C are incorrect because a home health agency provides care in the patient's home, a suicide prevention center focuses on mental health crisis intervention, and a state-owned psychiatric hospital offers mental health treatment, none of which are synonymous with extended care facilities.

2. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?

• A. Reporting the finding to the healthcare provider immediately
• B. Helping the woman stay in bed and rest
• C. Documenting the finding
• D. Performing active and passive range-of-motion exercises

Correct answer: C

Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.

3. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?

• A. The young adult is sensitive to criticism.
• B. The young adult verbalizes unrealistic fears.
• C. The young adult verbalizes disappointment with life.
• D. The young adult verbalizes satisfaction with friendships.

Correct answer: D

Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.

4. 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.

5. A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets the client's results in which way?

• A. The client is legally blind.
• B. The client has normal vision.
• C. The client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.
• D. The client can read at a distance of 80 feet what a client with normal vision can read at 20 feet.

Correct answer: D

Rationale: When interpreting visual acuity testing results using the Snellen chart, the recorded numeric fraction represents the distance the client is standing from the chart and the distance a normal eye could read that particular line. A reading of 20/80 means that the client can read at 20 feet what a client with normal vision can read at 80 feet. This indicates visual impairment but does not meet the criteria for legal blindness, which is defined as best-corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20. Therefore, the correct interpretation is that the client can read at a distance of 80 feet what a client with normal vision can read at 20 feet. Choice A is incorrect because 20/80 does not meet the criteria for legal blindness. Choice B is incorrect as the client's vision is impaired. Choice C is incorrect because it reverses the interpretation of the fraction.

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