Nursing Elites

1. The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?

• A. ''I should eat five or six small meals a day rather than three full meals.''
• B. ''I need to be sure not to drink liquids with my meals.''
• C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
• D. ''I need to avoid eating fried or greasy foods.''

Correct answer: B

Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.

2. A nurse assisting with data collection notes that the client's skin is very dry. The nurse documents this finding using which term?

• A. Xerosis
• B. Pruritus
• C. Seborrhea
• D. Actinic keratoses

Correct answer: A

Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Xerosis is the correct term for very dry skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin, but it does not specifically refer to dry skin. Seborrhea is a skin condition characterized by overproduction of sebum, leading to excessive oiliness or dry scales, not necessarily indicating very dry skin. Actinic keratoses are sun-related skin lesions that are premalignant and not associated with dry skin.

3. 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.

4. 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.

5. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

• A. Loss of hearing acuity
• B. A problem with balance
• C. A problem with distant hearing
• D. A problem discriminating high-pitched and low-pitched sounds

Correct answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

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