Nursing Elites

1. The healthcare provider is observing the way a patient walks. Which aspect is the healthcare provider assessing?

• A. Activity tolerance
• B. Body alignment
• C. Range of motion
• D. Gait

Correct answer: D

Rationale: When assessing the way a patient walks, the healthcare provider is evaluating the gait, which refers to a particular manner or style of walking. Body alignment pertains to the positioning of body parts in relation to one another, range of motion refers to the extent of movement of a joint, and activity tolerance relates to the ability to endure physical activities. In this scenario, observing the patient's walking pattern specifically focuses on gait assessment.

2. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

• A. Activate the emergency fire alarm
• B. Extinguish the fire
• C. Evacuate the client
• D. Confine the fire

Correct answer: C

Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.

3. During preoperative teaching, a client in a surgeon’s office expresses intent to prepare advance directives before surgery. Which statement by the client indicates understanding of advance directives?

• A. “I’d prefer my brother to make decisions, but I understand it must be my wife.”
• B. “I understand the surgery won’t proceed unless I fill out these forms.”
• C. “I plan to specify my wish to avoid being kept on a breathing machine.”
• D. “I will have my primary doctor review my plan before submitting it at the hospital.”

Correct answer: C

Rationale: The correct answer is C. This statement reflects the client's understanding of advance directives, as it indicates a specific preference regarding life-sustaining treatment. Advance directives enable individuals to outline their healthcare preferences, including decisions about treatments they wish to receive or avoid. Choice A mentions family members but doesn't address specific healthcare wishes; choice B focuses on the surgery rather than personal directives; choice D discusses doctor approval but lacks details about the directive itself.

4. During a skin assessment, a healthcare professional is observing a group of clients. Which of the following lesions should the healthcare professional identify as vesicles?

• A. Acne
• B. Warts
• C. Psoriasis
• D. Herpes simplex

Correct answer: D

Rationale: Vesicles are small fluid-filled blisters. Herpes simplex is an example of a vesicular lesion, characterized by small, fluid-filled blisters. Acne presents as comedones, papules, pustules, or nodules, not vesicles. Warts are caused by the human papillomavirus and appear as rough, raised growths. Psoriasis is a chronic autoimmune condition that results in red, scaly patches on the skin, not vesicles.

5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Mitral stenosis
• C. Aortic regurgitation
• D. Tricuspid stenosis

Correct answer: B

Rationale: The correct answer is B: Mitral stenosis. A high-pitched scratching sound heard during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border indicates mitral stenosis, not a pericardial friction rub. Pericardial friction rub is a to-and-fro, grating, or scratching sound due to inflamed pericardial surfaces rubbing together, typically heard in early diastole and late systole. Aortic regurgitation and tricuspid stenosis would present with different auscultatory findings compared to the described scenario, making them incorrect choices in this context.

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