Nursing Elites

1. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?

• A. Impaired verbalization
• B. Depressed mood
• C. Flat affect
• D. Diminished LOC

Correct answer: C

Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.

2. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?

• A. Omit the section of the assessment form
• B. Ask her if she would like an interpreter to help her understand the question
• C. Reword the question to make it more culturally sensitive
• D. Observe the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.

3. The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the drops are used to anesthetize the eye if eye pain is experienced. What action should the PN implement?

• A. Document in the chart that the client understands the correct action and use of eye drops
• B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common
• C. Reteach the client about the action of the eye drops to decrease pressure in the eyes
• D. Explain to the client that the eye drops do not anesthetize the eyes but reduce pressure

Correct answer: C

Rationale: Pilocarpine eye drops are used to reduce intraocular pressure in glaucoma, not to anesthetize the eye. The PN should reteach the client about the purpose of the medication to ensure proper use and understanding, which is crucial for effective treatment. Choice A is incorrect because just documenting understanding without addressing the client's misconception is not enough. Choice B is incorrect as it provides incorrect information about the purpose of the eye drops and may lead to further misunderstanding. Choice D is incorrect as it provides inaccurate information stating that the drops provide pain relief, which is not their primary purpose.

4. A nurse is reviewing the basal body temperature method with a couple. Which of the following statements would indicate that the teaching has been successful?

• A. I don't need to buy a special type of thermometer.
• B. I need to wait 5 minutes after smoking a cigarette before I take my temperature.
• C. I need to take my temperature before I get out of bed in the morning.
• D. I need to take my temperature at least once every day.

Correct answer: C

Rationale: The correct answer is C. Basal body temperature must be taken before getting out of bed in the morning to get an accurate reading, as even slight activity can raise body temperature and affect the results. Choice A is incorrect because a special type of thermometer is not required for basal body temperature measurement. Choice B is incorrect because smoking can affect body temperature, but the timing mentioned is not relevant to basal body temperature measurement. Choice D is incorrect because while it is essential to take the temperature consistently each day, the duration of temperature measurement is not specified, making this choice less specific compared to the correct answer.

5. The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement?

• A. Report the findings to the charge nurse
• B. Monitor the client's temperature hourly
• C. Offer the client fluids frequently
• D. Provide care to moisten oral mucosa

Correct answer: A

Rationale: The change in the client’s condition, especially confusion and a new cough, may indicate the onset of an infection such as pneumonia, which requires immediate attention. Reporting to the charge nurse ensures prompt evaluation and intervention. Monitoring the client's temperature hourly (Choice B) could be important but not the most critical at this point. Offering the client fluids frequently (Choice C) and providing care to moisten oral mucosa (Choice D) are not the priority interventions when facing potential signs of infection and confusion in the client.

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