Nursing Elites

1. You are caring for a 78-year-old woman who is wondering why she was diagnosed with glaucoma. Although she has several risk factors, which of these is not one of them?

• A. age
• B. blood pressure reading of 143/89
• C. Mexican-American heritage
• D. 20/80 vision

Correct answer: D

Rationale: Age over 60 and Mexican-American heritage are recognized as risk factors for glaucoma. Elevated blood pressure is also a risk factor due to its potential to cause optic nerve damage. While 20/80 vision indicates poor eyesight, it is not a direct causal factor for glaucoma. Glaucoma is mainly associated with factors like age, ethnicity, and certain medical conditions, rather than a specific visual acuity measurement. Therefore, 20/80 vision is not a risk factor for glaucoma, making it the correct answer. The other choices, such as age, Mexican-American heritage, and elevated blood pressure, are established risk factors for developing glaucoma, as they are associated with an increased likelihood of the condition.

2. The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?

• A. 6
• B. 8
• C. 12
• D. 16

Correct answer: C

Rationale: An 18-month-old child should have approximately 12 teeth. In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 - 6 = 12. The correct answer is 12. Choice A (6) is incorrect as it does not consider the child's age. Choices B (8) and D (16) are incorrect as they do not align with the dental development timeline and the specific age of the child in question.

3. A nurse is reading the report from the registered nurse for an initial home visit to a client with chronic obstructive pulmonary disease. The client was recently discharged from the hospital. Which type of database does the nurse read that contains this information from the client?

• A. Episodic
• B. Follow-up
• C. Emergency
• D. Complete

Correct answer: D

Rationale: The correct answer is 'Complete.' A complete database includes a full health history and physical examination, providing a comprehensive overview of the client's current and past health status. This type of database establishes a baseline for future assessments, making it essential for the nurse's initial home visit to understand the client's health needs thoroughly post-hospital discharge. It is typically gathered in primary care settings like clinics, private practices, college health services, women's health care agencies, visiting nurse agencies, or community health agencies. An episodic database focuses on a specific short-term issue or body system, which is not comprehensive enough for the initial home visit after hospital discharge. A follow-up database is used to monitor a known problem at regular intervals, not suitable for an initial assessment. An emergency database is swiftly collected during urgent situations, often while lifesaving measures are being carried out, and is not relevant for a post-hospital discharge home visit.

4. When assessing Mr. Lee's eye condition, what general information should the nurse seek?

• A. Type of employment.
• B. Burning or itchy sensation in the eyes.
• C. Position of the eyelids.
• D. Existence of floaters.

Correct answer: A

Rationale: When assessing a patient's eye condition, the nurse should seek general information such as the type of employment, activities, allergies, medications, lenses, and protective devices used. This information helps in understanding potential exposures to irritants and risks related to activities. While the presence of burning or itchy sensation in the eyes, position of the eyelids, and existence of floaters are important aspects to assess during a focused eye examination, during the initial assessment, the type of employment is more relevant for understanding possible environmental factors affecting eye health.

5. 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.

Similar Questions