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. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

• A. nausea and vomiting
• B. itching
• C. urinary retention
• D. somnolence

Correct answer: B

Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.

3. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?

• A. Coffee
• B. A tuning fork
• C. A wisp of cotton
• D. An ophthalmoscope

Correct answer: C

Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.

4. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

• A. immobility
• B. altered growth and development
• C. hemarthrosis
• D. altered family processes

Correct answer: D

Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.

5. The LPN participates in a home visit for a client with Type 2 Diabetes who has been taking Metformin for 3 years. The client states that for the past 3 months, they have been trying a vegan diet and experiencing fatigue, confusion, and mood changes. What is a likely cause of the new symptoms?

• A. vitamin B12 deficiency
• B. chronic hypoglycemia
• C. vitamin D deficiency
• D. increased tolerance to Metformin

Correct answer: A

Rationale: The correct answer is vitamin B12 deficiency. Long-term use of Metformin can lead to vitamin B12 deficiency, and a vegan diet is low in vitamin B12. Symptoms of vitamin B12 deficiency include anemia, fatigue, confusion, and mood changes. Chronic hypoglycemia is unlikely in a client with Type 2 Diabetes who has been taking Metformin as it typically causes hyperglycemia. Vitamin D deficiency usually presents with symptoms related to bones and muscles, not confusion and mood changes. Increased tolerance to Metformin does not explain the client's new symptoms, which are more indicative of a nutritional deficiency like vitamin B12.

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