Nursing Elites

1. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?

• A. When the infant is sleeping
• B. At the end of the examination
• C. Before auscultation of the thorax
• D. At about the middle of the examination

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.

2. When assessing a pulse, what should be noted?

• A. Rate
• B. Rate and quality
• C. Rate, quality, and fullness
• D. Rate, quality, fullness, and regularity

Correct answer: C

Rationale: When assessing a pulse, it is important to note the rate (number of beats per minute), quality (regular or irregular), and fullness (thread and weak or full and bounding). These aspects provide crucial information about the patient's cardiovascular status. Regularity, as mentioned in option D, is not typically assessed during a pulse check and is not necessary for routine pulse assessment. Choice A is too limited as it overlooks important aspects beyond just the rate. Choice B improves by adding quality but still lacks the fullness aspect. Choice C is the most comprehensive and accurate as it includes all three essential aspects for a thorough pulse assessment.

3. The client starting an exercise program will progress to walking a 20-minute mile in one month.

• A. Client will walk quickly three times a day
• B. Client will be able to walk a mile
• C. Client will have no alteration in breathing during the walk
• D. Client will progress to walking a 20-minute mile in one month

Correct answer: D

Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. Choice A lacks specificity and does not mention a target time or goal. Choice B is vague and does not provide a specific target for improvement. Choice C focuses on a negative outcome (no alteration) rather than a positive goal. The correct answer, Choice D, is specific, measurable, and time-bound, making it a suitable outcome statement for a client starting an exercise program.

4. Mr. Thomas is a well-groomed 68-year-old male patient who had prostate surgery two days ago. He has an indwelling catheter and a urinary drainage bag. You have weighed him at 9 am each morning for 3 mornings in a row. Today, on the 4th day, his morning weight is 3 pounds more than it was the day before. Why could he have gained these 3 pounds in one day, on a 1000 calorie diet?

• A. It is obvious that his visitors have been sneaking him junk food from the local fast-food restaurant.
• B. It may be that his urinary drainage bag was not emptied today and it was emptied on previous days.
• C. It is obvious that the scale is broken and it should be replaced immediately to prevent these false weights.
• D. A 3-pound weight gain is not significant enough to question and should just be noted.

Correct answer: B

Rationale: The correct answer is that the weight gain may be due to the urinary drainage bag not being emptied today, while it was emptied on previous days. This scenario is common and can lead to an increase in weight that is not related to food intake. Choice A is incorrect because assuming visitors are sneaking junk food is speculative and not based on facts. Choice C is incorrect as there is no evidence to suggest the scale is broken. Choice D is incorrect because any unexplained weight gain should be investigated further, even if it seems insignificant at first.

5. A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?

• A. Citrus fruits
• B. Milk
• C. Fish
• D. Potatoes

Correct answer: B

Rationale: Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.

Similar Questions