Nursing Elites

1. Which of the following statements is correct about Maslow's hierarchy of needs?

• A. There are psychosocial interventions that may be applicable to all of the levels.
• B. There are physical interventions that may be applicable to all of the levels.
• C. Two of the levels may require physical intervention while four of the levels may require psychosocial intervention.
• D. Four of the levels may require physical intervention, while two of the levels may require psychosocial intervention.

Correct answer: C

Rationale: The correct statement about Maslow's hierarchy of needs is that two of the levels may require physical intervention while four of the levels may require psychosocial intervention. Maslow's theory suggests that physiological and safety needs are more basic and may require physical interventions, while social, esteem, and self-actualization needs are more psychosocial. Choices A and B are incorrect as they wrongly suggest that all levels may require only one type of intervention. Choice D is incorrect because it inaccurately represents the balance of physical and psychosocial interventions in Maslow's hierarchy of needs.

2. A nurse is explaining a nonstress test to a pregnant client. The nurse explains that the results are nonreactive if which finding is noted on the electronic monitoring recording strip?

• A. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats/min above baseline and lasting 15 seconds from baseline to baseline
• B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats/min for 15 seconds
• C. Acceleration of the FHR by 25 to 30 beats/min for at least 15 seconds in response to fetal movement
• D. Absence of accelerations after fetal movement

Correct answer: D

Rationale: The correct answer is 'Absence of accelerations after fetal movement.' In a nonreactive (nonreassuring) stress test, the monitor recording would not show accelerations after fetal movement within a 40-minute period. This absence of accelerations indicates a nonreactive result. Choices A, B, and C describe different patterns of fetal heart rate accelerations that are not indicative of a nonreactive result in a nonstress test, making them incorrect. Choice A describes the characteristics of a reactive (reassuring) result, where there should be at least two fetal heart accelerations within a 20-minute period, peaking at least 15 beats/min above the baseline, and lasting 15 seconds from baseline to baseline. Choice B incorrectly states 'Accelerations without fetal movement,' which is contradictory. Choice C describes an acceleration response to fetal movement, which does not signify a nonreactive result.

3. A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?

• A. Asking the client to raise their eyebrows and looking for symmetry
• B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle
• C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face
• D. Asking the client to close their eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear

Correct answer: D

Rationale: To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing. Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).

4. Mr. H. is upset about being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:

• A. the right to examine and question the bill
• B. the right to reasonable response to requests
• C. the right to refuse treatment
• D. the right to confidentiality

Correct answer: D

Rationale: Confidentiality is the maintenance of privacy of information, which is not directly related to the issue Mr. H. is facing. The question indicates that Mr. H. is concerned about the cost of staying in the hospital, which pertains more to financial aspects and the right to examine and question the bill. The right to a reasonable response to requests and the right to refuse treatment are also crucial patient rights that Mr. H. may demand in his current situation. Therefore, the correct answer is the right to confidentiality, as it is not specifically relevant to the scenario presented.

5. A male client is learning about testicular self-examination (TSE) from a nurse. Which statement should the nurse make to the client?

• A. 'A good time to examine the testicles is during or after you take a shower.'
• B. 'If you notice an enlarged testicle or a lump, you need to notify the physician.'
• C. 'The testicle is round and smooth. It feels firm and without lumps.'
• D. 'Perform a testicular exam monthly to detect early signs of testicular cancer.'

Correct answer: B

Rationale: The correct statement for the nurse to make to the client is 'If you notice an enlarged testicle or a lump, you need to notify the physician.' During a shower or bath is the best time to examine the testes because warm temperatures make the testes hang lower in the scrotum. The testes should feel round and smooth, without lumps. Self-examination should be performed monthly to detect any abnormalities early. The physician needs to be notified immediately if any abnormal findings are noticed. Choice A is incorrect because the best time for TSE is during or after a warm shower or bath, not just before. Choice C is incorrect as the testicle should feel round, smooth, and without lumps, not egg-shaped and lumpy. Choice D is incorrect as monthly self-examinations are recommended, not every 2 months.

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