Nursing Elites

1. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.

2. The difference between spirituality and religion is that spirituality is:

• A. a belief about a higher power.
• B. an individual's relationship with a higher power.
• C. organized worship.
• D. a belief in an invisible energy or ideal.

Correct answer: B

Rationale: The correct answer is 'an individual's relationship with a higher power.' Spirituality is more about personal connection, beliefs, and experiences related to a higher power or force, whereas religion is often associated with organized practices, rituals, and doctrines within a specific faith community. Choice A is incorrect as spirituality goes beyond just believing in a higher power; it encompasses a personal connection. Choice C, 'organized worship,' is incorrect because spirituality can exist outside formal religious settings. Choice D is incorrect as it oversimplifies spirituality as merely a belief in an invisible energy or ideal, missing the relational aspect with a higher power.

3. A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?

• A. Uses a tuning fork
• B. Asks the client to puff out the cheeks
• C. Tests taste perception on the client's tongue
• D. Checks the client's ability to clench the teeth

Correct answer: A

Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.

4. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?

• A. A client with AIDS being treated with Foscarnet
• B. A client with a fractured femur in a long leg cast
• C. A client with laryngeal cancer with a laryngectomy
• D. A client with diabetic ulcers on the left foot

Correct answer: C

Rationale: The correct answer is the client with laryngeal cancer who had a laryngectomy. This client is at risk for airway obstruction due to the surgical procedure, making it a priority visit. Clients with AIDS (choice A), a fractured femur (choice B), and diabetic ulcers (choice D) do not have immediate life-threatening conditions that require urgent attention compared to a client with a recent laryngectomy.

5. Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?

• A. The schizophrenic client experiencing visual and auditory hallucinations and the client with ulcerative colitis
• B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
• C. A child with fixed and dilated pupils and his parents, and the client with a frontal head injury
• D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

Correct answer: B

Rationale: The correct answer is to assign the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm to share a room. The pregnant client needs close monitoring due to the abdominal pain, and the client with facial lacerations and a broken arm requires immediate attention for wound care and possible fracture management. Choice A should not be assigned together as the schizophrenic client experiencing visual and auditory hallucinations needs a separate room for privacy and safety, and the client with ulcerative colitis may require isolation due to the risk of infection. Choice C is incorrect because the child with fixed and dilated pupils is likely in a critical condition and should be in a private room with parents, while the client with a frontal head injury needs a separate room for focused care. Choice D is also incorrect as the client with a large puncture wound to the abdomen needs immediate attention in a separate room, and the client with chest pain requires evaluation and monitoring in a separate setting as well.

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