Nursing Elites

1. After performing the appropriate client assessment, which of the following inferences would the nurse make?

• A. Client is hypotensive
• B. Respiratory rate of 20 breaths per minute
• C. Oxygen saturation of 95%
• D. Client relays anxiety about blood work

Correct answer: A

Rationale: An inference is the nurse's judgment or interpretation of cues gathered during an assessment. In this scenario, identifying a client as hypotensive would be an inference based on blood pressure readings that indicate lower than normal values. Respiratory rate and oxygen saturation levels (choices B and C) are important cues that provide additional data but do not directly point to a specific conclusion like hypotension. The client expressing anxiety about blood work (choice D) is relevant information but relates more to their emotional state rather than a physiological assessment finding.

2. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

• A. Tell the patient, 'Please remain silent while I count your number of breaths.'
• B. Count respirations at the same time you are counting the pulse rate
• C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
• D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

3. What does the term 'Afferent Nerve' mean?

• A. Carrying an impulse to the brain
• B. Carrying an impulse away from the brain
• C. Carrying impulses to the motor neurons of the appendicular muscles
• D. None of the above

Correct answer: A

Rationale: The correct answer is 'Carrying an impulse to the brain.' Afferent nerves are sensory nerves that carry signals from sensory receptors towards the central nervous system, including the brain. Choice B, 'Carrying an impulse away from the brain,' is incorrect as this describes efferent nerves which carry signals from the central nervous system to muscles and glands. Choice C, 'Carrying impulses to the motor neurons of the appendicular muscles,' is incorrect as it describes a different type of nerve function. Choice D, 'None of the above,' is incorrect as the correct definition of afferent nerve is indeed 'Carrying an impulse to the brain.'

4. All of the following factors may contribute to client falls EXCEPT:

• A. Contact dermatitis
• B. Urinary frequency
• C. Decreased visual acuity
• D. Confusion

Correct answer: A

Rationale: Client falls can result from various factors, both intrinsic and extrinsic. Intrinsic factors include health conditions like urinary frequency, which increases the need for bathroom visits, decreased visual acuity, and confusion. These factors can directly contribute to an increased risk of falls. However, contact dermatitis does not directly lead to falls. Contact dermatitis is a skin condition caused by contact with irritants or allergens and does not inherently predispose individuals to falling. Therefore, among the given options, contact dermatitis is the only factor that is not directly associated with an increased risk of falls.

5. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?

• A. After menopause, blood pressure readings in women are usually higher than those taken in men.
• B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
• C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
• D. A teenager's blood pressure reading may be lower than that of an adult.

Correct answer: B

Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.

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