Nursing Elites

1. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

2. How often should a 5-year-old child undergo a dental examination?

• A. Every 6 months
• B. Whenever a new primary tooth erupts
• C. Once a year
• D. Every 3 months

Correct answer: A

Rationale: For a 5-year-old child, dental examinations should be conducted every 6 months. This frequency allows for early detection of dental issues and promotes good oral health. Choices B, C, and D are incorrect because waiting for a new primary tooth to erupt, having an examination once a year, or every 3 months are not the recommended intervals for dental check-ups in this age group. It is essential to adhere to the standard guideline of every 6 months to ensure regular monitoring and preventive care for the child's dental health.

3. In a community pediatric health clinic, which developmental task should you apply into your practice?

• A. You should apply the principles of initiative when caring for preschool children.
• B. You should apply the principles of sensorimotor thought when caring for preschool children.
• C. You should apply the principles of intimacy when caring for the adolescent.
• D. You should apply the principles of concrete operations when caring for the adolescent.

Correct answer: A

Rationale: When working in a community pediatric health clinic, applying the principles of initiative is crucial when caring for preschool children. According to Erik Erikson's psychosocial theory, the developmental task for preschool children is initiative. Preschool children are in the stage where they are eager to initiate activities and carry out tasks. This stage is characterized by a balance between initiative and guilt. By encouraging children to explore and take the initiative in a supportive environment, healthcare providers can foster their sense of independence and creativity. The other choices are incorrect because: - Sensorimotor thought is a term associated with Jean Piaget's cognitive development theory, not Erikson's psychosocial theory. - Intimacy is a developmental task associated with young adults, not adolescents, in Erikson's theory. - Concrete operations is a term linked to Piaget's theory of cognitive development and is not a developmental task according to Erikson's psychosocial theory.

4. A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?

• A. Dull sounds
• B. Hyperresonance sounds
• C. Hypoactive bowel sounds
• D. An absence of bowel sounds

Correct answer: A

Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.

5. A nurse is preparing to assist the healthcare provider in performing an internal gynecological examination of a client. In which position does the nurse place the client for this examination?

• A. Prone
• B. Left side-lying
• C. Sims
• D. Lithotomy

Correct answer: D

Rationale: An internal gynecological examination is performed with the client in the lithotomy position. In this position, the client is supine, with the feet in stirrups, the knees apart, and the buttocks at the end of the examining table. The client is draped so that only the vulva is exposed. The lithotomy position provides optimal access for the healthcare provider to perform the examination effectively. The prone position refers to lying on the stomach, which is not suitable for a gynecological exam. The Sims position is a left side-lying position primarily used for administering enemas, not for gynecological examinations.

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