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. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

• A. Risk for Self-Harm
• B. Body Image Disturbance
• C. Ineffective Role Performance
• D. Powerlessness

Correct answer: B

Rationale: The correct answer is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and completeness related to infertility, indicating a disturbance in body image perception. 'Risk for Self-Harm' is not the best choice as there is no indication of immediate self-harm. 'Ineffective Role Performance' is less appropriate since the statement does not directly relate to a disruption in the parent's role. 'Powerlessness' could be considered if the client expressed feelings of powerlessness specifically related to the infertility issue.

3. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

• A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
• B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
• C. The organ procurement organization makes the decision regarding which organs to harvest.
• D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.

Correct answer: A

Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.

4. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?

• A. turning out the room light and closing the door
• B. tiring the child during the evening with quiet activities
• C. identifying the child's home bedtime rituals and following them
• D. encouraging visitation by friends during the evening

Correct answer: C

Rationale: For a 4-year-old client struggling to sleep in the hospital, it is essential to identify and replicate their home bedtime rituals. This familiarity can provide comfort and promote better sleep. Turning out the room light and closing the door (Choice A) might increase the child's fear by plunging the room into darkness, making it an incorrect choice. Tiring the child with quiet activities (Choice B) is incorrect as it may stimulate rather than calm the child. Encouraging visitation by friends (Choice D) can lead to increased excitement, hindering the child's ability to fall asleep instead of promoting a restful environment.

5. A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?

• A. Smiling
• B. Clenching the teeth
• C. Shrugging the shoulders against the nurse's resistance
• D. Identifying by taste a substance placed on the back of the tongue

Correct answer: C

Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.

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