Nursing Elites

1. Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?

• A. Liver
• B. Spleen
• C. Pancreas
• D. Appendix

Correct answer: D

Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.

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. As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?

• A. builds towers with several blocks
• B. tries to color within the lines
• C. says 'Mine!' when playing with toys
• D. tries to jump rope

Correct answer: C

Rationale: The correct answer is C: 'says 'Mine!' when playing with toys.' At the age of 2, children are in the stage of parallel play and are possessive of their belongings, hence saying 'Mine!' is an age-appropriate behavior. Building towers with blocks (choice A) involves more advanced motor skills and cognitive abilities, which are beyond what most 2-year-olds can do. Trying to color within the lines (choice B) requires fine motor skills that are typically not developed at age 2. Jumping rope (choice D) involves coordination and balance that are beyond the capabilities of a 2-year-old child.

4. The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother?

• A. Infection always occurs when body piercing is done
• B. Hepatitis B is a concern with body piercing
• C. Body piercing is generally harmless as long as it is performed under sterile conditions
• D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)

Correct answer: C

Rationale: Generally, body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some complications that may occur include bleeding, infection, keloid formation, and the development of allergies to metal. It is essential to clean the area at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not typically associated with body piercing; however, they are a possibility with tattooing. Choice A is incorrect because infection does not always occur when body piercing is done. Choice B is not the best answer as hepatitis B is not commonly associated with body piercing. Choice D is incorrect because the risk of contracting HIV is not a significant concern with body piercing if performed under sterile conditions.

5. What type of immunity do vaccines provide?

• A. active
• B. passive
• C. transplacental
• D. active and passive

Correct answer: A

Rationale: Vaccines provide active immunity by stimulating the immune system to produce antibodies against specific pathogens. Choice B, passive immunity, is acquired from ready-made antibodies, not through vaccination. Choice C, transplacental immunity, is a form of passive immunity transferred from mother to infant, not acquired through vaccines. Therefore, the correct answer is active immunity.

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