Nursing Elites

1. When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?

• A. Notify the physician.
• B. Record this finding as normal.
• C. Check the child's blood pressure and note any variation with respiration.
• D. Document that this child has bradycardia and continue with the assessment.

Correct answer: B

Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.

2. Why should a palpated pressure be performed before auscultating blood pressure?

• A. To more clearly hear the Korotkoff sounds.
• B. To detect the presence of an auscultatory gap.
• C. To avoid missing a falsely elevated blood pressure.
• D. To more readily identify phase IV of the Korotkoff sounds.

Correct answer: B

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.

3. Which of the following statements best describes substance P?

• A. Substance P decreases a client's sensitivity to pain
• B. Substance P levels are drawn before administration of narcotic analgesics
• C. Substance P is found in the brain and is responsible for pain control and management of depression
• D. Substance P is found in the dorsal horn of the spinal column

Correct answer: D

Rationale: Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.

4. The healthcare provider is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?

• A. Holistic
• B. Biomedical
• C. Naturalistic
• D. Magicoreligious

Correct answer: B

Rationale: The correct answer is B: Biomedical. Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic or holistic perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health. Therefore, options A, C, and D are incorrect as they do not align with the germ theory explanation provided in the question.

5. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?

• A. The client most likely has a mental illness that should be treated before addressing sleep issues
• B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
• C. The client may become tired once they start talking
• D. None of the above

Correct answer: B

Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.

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