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 home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

3. A client with a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management asks how it works. What information should the nurse reinforce?

• A. The discharge of electricity will distract the client's focus from the pain
• B. An infusion of medication in the spinal canal will block pain perception
• C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
• D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain

Correct answer: D

Rationale: The correct answer is D. TENS works by delivering a mild electrical stimulus that can block pain signals from reaching the brain, effectively reducing the perception of pain. Choice A is incorrect because TENS does not distract from pain but rather interferes with pain signals. Choice B is incorrect as TENS does not involve infusing medication into the spinal canal. Choice C is also incorrect because TENS does not target the cerebral cortex to dull pain perception but rather works at the level of nerve conduction.

4. The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?

• A. Ask another nurse to return with the medication when the client has hung up the phone
• B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
• C. Return the medication to the client's drawer on the cart and document that the client refused the dose
• D. Leave the medication with the client and let him take it when he finishes the conversation

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.

5. Inspiratory and expiratory stridor may be heard in a client who:

• A. Is experiencing an exacerbation of goiter
• B. Is experiencing an acute asthmatic attack
• C. Has aspirated a piece of meat
• D. Has severe laryngotracheitis

Correct answer: D

Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.

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