Nursing Elites

1. To which of the following do the CDC Standard precautions recommendations apply?

• A. Patients with diagnosed infections only
• B. Blood or body fluids with visible blood only
• C. All body fluids including sweat
• D. All patients receiving care in hospitals

Correct answer: D

Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.

2. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?

• A. Asking questions may enhance the child's autonomy.
• B. Asking the child for permission helps develop a sense of trust.
• C. This question is an inappropriate statement because children at this age like to have choices.
• D. Children at this age like to say, "No."? The examiner should not offer a choice when no choice is available.

Correct answer: D

Rationale: Children at the age of 2 often like to assert their independence by saying "No."? In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, "Shall I listen to your heart next or your tummy?"? may be a better approach. Therefore, the correct critique of the nurse's technique in this scenario is that children at this age tend to say "No,"? so the examiner should avoid offering a choice when there isn't a real alternative.

3. While performing the physical examination, why does the nurse share information and briefly teach the patient?

• A. To help the patient feel more comfortable and gain control of the situation
• B. To build rapport and increase the patient's confidence in the examiner
• C. To assist the patient in understanding his or her disease process and treatment modalities
• D. To aid the patient in identifying questions about his or her disease and potential areas of needed education

Correct answer: B

Rationale: Sharing information and briefly teaching the patient during a physical examination helps build rapport and increase the patient's confidence in the examiner. This approach gives the patient a sense of control in a situation that can often be overwhelming. While sharing information may make the patient feel more comfortable, the primary goal is to enhance the patient's confidence in the examiner. Providing information does not necessarily directly assist the patient in understanding their disease process and treatment modalities, as this may require a more in-depth explanation. The main focus is on establishing a trusting relationship and empowering the patient during the examination, rather than solely aiding in identifying questions or areas needing education.

4. Which of the following is an example of emotional abuse?

• A. A slap to the person's hand
• B. Threatening the person
• C. Ignoring and isolating a person
• D. Leaving a patient soiled for hours

Correct answer: C

Rationale: Emotional abuse involves behaviors that harm an individual's self-worth and emotional well-being. Threatening someone instills fear and causes psychological distress, making it a clear example of emotional abuse. Choices A, C, and D involve physical abuse, neglect, and neglect of care, respectively, rather than emotional abuse. A slap to the person's hand constitutes physical abuse, ignoring and isolating a person is neglectful behavior, and leaving a patient soiled for hours falls under neglect of care.

5. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

• A. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
• B. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
• C. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
• D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

Correct answer: B

Rationale: The correct answer is the 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism, which requires immediate assessment and action such as oxygen administration to maintain adequate oxygenation. The other patients should also be assessed as soon as possible, but they do not present with an immediate life-threatening condition that requires urgent intervention like the patient experiencing sudden shortness of breath.

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