Nursing Elites

1. Which of the following is an anthropometric measurement?

• A. Blood pressure
• B. Temperature
• C. Pulse Rate
• D. Weight

Correct answer: D

Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.

2. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?

• A. Asking questions may enhance the child's autonomy.
• B. Asking the child for permission helps develop a sense of trust.
• C. This question is an inappropriate statement because children at this age like to have choices.
• D. Children at this age like to say, "No."? The examiner should not offer a choice when no choice is available.

Correct answer: D

Rationale: Children at the age of 2 often like to assert their independence by saying "No."? In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, "Shall I listen to your heart next or your tummy?"? may be a better approach. Therefore, the correct critique of the nurse's technique in this scenario is that children at this age tend to say "No,"? so the examiner should avoid offering a choice when there isn't a real alternative.

3. When a patient refuses to believe a terminal diagnosis, they are exhibiting:

• A. Regression
• B. Mourning
• C. Denial
• D. Rationalization

Correct answer: C

Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.

4. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

• A. The skin on the arm appears mottled
• B. The cold pack has been in place for 10 minutes
• C. The client complains of feeling nauseated
• D. The capillary refill in the area distal to the arm is 2 seconds

Correct answer: A

Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.

5. Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:

• A. Institute complete bed rest for the client
• B. Assess uterine tone to determine condition
• C. Perform a vaginal exam to assess cervical dilation
• D. Measure and record blood loss each shift

Correct answer: C

Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.

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