Nursing Elites

1. Why does Anita stand in front of the mirror while performing a Breast Self-Examination (BSE)?

• A. To check for unusual discharges from the breast
• B. To check for any obvious malignancy
• C. To observe the size and contour of the breast
• D. To check for thickness and lumps in the breast

Correct answer: C

Rationale: When performing a Breast Self-Examination (BSE), one of the reasons for standing in front of a mirror is to observe the size and contour of the breast (Choice C). This helps in identifying any visible changes or abnormalities such as dimpling, puckering, or changes in the size and shape of the breasts. While unusual discharges (Choice A) and thickness or lumps (Choice D) can be part of the changes a person might notice during a BSE, these are typically identified by palpation or by squeezing the nipple for discharge, not by just looking in the mirror. Choice B, checking for obvious malignancy, is too vague and not specific enough as malignancy is often not visible to the naked eye.

2. High blood pressure is defined as systolic and diastolic measurements greater than or equal to:

• A. 140 mm Hg and 90 mm Hg, respectively
• B. 150 mm Hg and 80 mm Hg, respectively
• C. 160 mm Hg and 110 mm Hg, respectively
• D. 180 mm Hg and 120 mm Hg, respectively

Correct answer: A

Rationale: High blood pressure, or hypertension, is typically defined as having a systolic pressure of 140 mm Hg or higher and/or a diastolic pressure of 90 mm Hg or higher. Therefore, the correct answer is A. Choice B is incorrect because it suggests a higher systolic measurement than the standard definition. Choice C is incorrect as it provides an even higher systolic measurement and a much higher diastolic measurement. Choice D is also incorrect as it suggests extremely elevated blood pressure values, well above the typical definition of hypertension.

3. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

4. Where should a nurse auscultate the apex beat?

• A. At the fifth intercostal space, along the midclavicular line
• B. At the mid-sternum
• C. 2 inches to the left of the lower end of the sternum
• D. 1 inch to the left of the xiphoid process

Correct answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

5. What type of drug therapy is typically administered immediately after a heart attack?

• A. Antilipemic drugs
• B. Corticosteroids
• C. Diuretics
• D. Thrombolytic drugs

Correct answer: D

Rationale: Thrombolytic drugs are typically administered immediately after a heart attack to dissolve the clot blocking the coronary artery and restore blood flow to the heart muscle. Antilipemic drugs are used to lower lipid levels and prevent atherosclerosis, but they are not typically administered immediately after a heart attack. Corticosteroids are used to reduce inflammation and suppress the immune response, which are not immediate concerns after a heart attack. Diuretics are used to reduce fluid build-up and lower blood pressure, but these are not the primary concerns immediately following a heart attack.

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