Nursing Elites

1. While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?

• A. Pyrosis
• B. Anorexia
• C. Eructation
• D. Dysphagia

Correct answer: D

Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.

2. Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:

• A. tolerance.
• B. constipation.
• C. sedation.
• D. addiction.

Correct answer: D

Rationale: The correct answer is 'addiction.' When caring for clients with cancer who are taking opioids, nurses need to assess for tolerance, constipation, and sedation as these are common side effects of opioid use. Addiction is not a primary concern when managing pain in terminally ill clients, as the goal is effective pain management rather than addiction prevention. Tolerance refers to the body's adaptation to the opioid over time, requiring higher doses for the same effect. Constipation and sedation are common side effects of opioids that nurses need to monitor and manage. Addiction is not a major concern in this population as the focus is on providing comfort and pain relief.

3. A nurse assisting with data collection of the peripheral vascular system performs the Allen test. The nurse understands that this test is used to determine the patency of which blood vessel(s)?

• A. Capillaries
• B. Pedal pulses
• C. Femoral arteries
• D. Radial and ulnar arteries

Correct answer: D

Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client's ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen. Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries. Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot. Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.

4. A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse uses which technique?

• A. Tests the right eye, then tests the left eye, and finally tests both eyes together
• B. Assesses both eyes together, then assesses the right and left eyes separately
• C. Asks the client to stand 40 feet from the chart and read the largest line on the chart
• D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision

Correct answer: A

Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot at the client's eye level, with the client positioned exactly 20 feet from the chart. The client shields one eye at a time with an opaque card during the test. After testing each eye separately, both eyes are assessed together. The client is asked to read the smallest line of letters visible and encouraged to read the next smallest line as well. Therefore, option A is correct as it describes the correct technique of testing one eye at a time before assessing both eyes together. Option B is incorrect as it assesses both eyes together first, which is not the standard procedure. Options C and D are incorrect as they suggest standing 40 feet from the chart, which contradicts the standard distance of 20 feet for a Snellen chart test.

5. In the context of diagnostic genetic counseling, which of the following choices is typically not made by clients?

• A. Terminating the pregnancy.
• B. Preparing for the birth of a child with special needs.
• C. Accessing support services before the birth.
• D. Completing the grieving process before the birth.

Correct answer: D

Rationale: In diagnostic genetic counseling, clients may face difficult decisions based on test results. Terminating the pregnancy is a choice some clients may consider if severe abnormalities are detected. Preparing for the birth of a child with special needs involves getting ready to care for a child who may require extra attention and support. Accessing support services before the birth can help clients connect with resources and professionals for assistance during and after the pregnancy. Completing the grieving process before birth is not typically a choice made in the context of genetic counseling. The grieving process often starts or continues after distressing results and can extend beyond the birth of the child. Therefore, the correct answer is completing the grieving process before the birth.

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