Nursing Elites

1. A nurse is assigned to care for a deaf client. During her lunch hour, she visits the hospital library and reads more about deaf culture in order to better provide appropriate care for her client. This action is an example of:

• A. Cultural knowledge
• B. Cultural noise
• C. Cultural diversity
• D. Cultural divide

Correct answer: A

Rationale: Cultural knowledge involves seeking information and educating oneself about different cultural groups. In this scenario, the nurse is demonstrating cultural knowledge by learning more about deaf culture to improve the care provided to the deaf client. This proactive approach helps in understanding the client's background, beliefs, and communication preferences, leading to better outcomes. 'Cultural noise' and 'Cultural divide' are incorrect as they do not reflect the nurse's positive action of seeking knowledge to enhance care. 'Cultural diversity' is also incorrect as it does not accurately describe the nurse's specific action of acquiring knowledge about a particular culture.

2. What would a healthcare professional expect to observe while assessing the growth of children during their school-age years?

• A. Decreasing amounts of body fat and muscle mass
• B. Little change in body appearance from year to year
• C. Progressive height increase of 4 inches each year
• D. Yearly weight gain of about 5.5 pounds per year

Correct answer: D

Rationale: During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years. Choice A is incorrect as children at this stage are expected to gain weight and grow in height. Choice B is incorrect as there should be noticeable changes in body appearance due to growth. Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.

3. You are taking care of Mary Eden, an elderly and frail 91-year-old resident. She gets confused during evening hours and at times she thinks that she hears her daughter calling her from the other side of the nursing home. Which physical problem places Mary Eden at risk for falls?

• A. Her confusion
• B. Her daughter
• C. Evening hours
• D. Her frailness

Correct answer: D

Rationale: Mary Eden's frail and weak muscles due to her age and physical condition place her at risk for falls. While her confusion can contribute to falls, it is considered an emotional or cognitive issue rather than a physical problem. Her daughter and the evening hours are not physical problems that directly increase her risk of falling.

4. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?

• A. External light sources may cause falsely high oximetry values
• B. A bright light in the client's face may cause a low pulse oximetry
• C. External light sources may cause falsely low oximetry values
• D. The client needs a dark and quiet room to recover and maintain proper oxygenation

Correct answer: A

Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.

5. A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?

• A. Ask the client to undress to assess for injuries
• B. Take the client into a private room
• C. Notify the police to file a report
• D. Notify the house supervisor to keep security on alert

Correct answer: B

Rationale: When dealing with a client suspected of domestic violence, it is crucial to provide privacy and a safe environment. Taking the client into a private room allows for a confidential conversation and assessment without compromising the client's safety or dignity. The nurse should prioritize creating a safe space for the client to share information and receive support. Notification of authorities should only occur once a thorough assessment has been conducted to ensure the client's safety and well-being. Option A is incorrect because asking the client to undress should be done with sensitivity and respect for the client's privacy, focusing on assessing injuries rather than visualizing them. Option C is premature as involving the police should be based on a comprehensive assessment and the client's consent. Option D is not the most immediate and direct action required to address the client's immediate needs in a suspected domestic violence situation.

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