Nursing Elites

1. The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?

• A. Ask the healthcare provider about referring the client to a neurological specialist.
• B. Obtain a prescription for a muscle relaxant.
• C. Notify the healthcare provider immediately.
• D. Document the findings.

Correct answer: D

Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.

2. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

3. A nurse is participating in a planning conference to improve dietary measures for an older client experiencing dysphagia. Which action should the nurse suggest including in the plan of care?

• A. Monitoring the client during meals to ensure that food is swallowed
• B. Encouraging the client to feed themselves
• C. Consulting with the physician regarding feeding through an enteral tube
• D. Ensuring that the diet consists of both solids and liquids

Correct answer: A

Rationale: For clients with dysphagia, ensuring successful swallowing of food and preventing aspiration is crucial. Therefore, the nurse should suggest monitoring the client closely during meals to provide assistance as needed. While a balanced diet is important, special considerations like adding thickeners for liquids may be required for dysphagia clients. Consulting with a physician about enteral tube feeding should be based on the severity of the condition, making it a premature step without clear indications. Encouraging self-feeding may not be appropriate for dysphagia clients who require close monitoring and assistance, as it could increase the risk of complications.

4. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

• A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
• B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
• C. The organ procurement organization makes the decision regarding which organs to harvest.
• D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.

Correct answer: A

Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.

5. A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

• A. The client has a fever.
• B. The skin temperature is normal.
• C. The client needs to drink additional fluids.
• D. The client needs to have the blanket removed.

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

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