Nursing Elites

1. How should a client's neck be positioned for palpation of the thyroid?

• A. flexed toward the side being examined
• B. hyperextended directly backward
• C. flexed away from the side being examined
• D. flexed directly forward

Correct answer: A

Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.

2. A nurse preparing to assist with data collection of the abdomen asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?

• A. Dullness
• B. Tympany
• C. Borborygmus
• D. Hyperresonance

Correct answer: B

Rationale: The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is in a supine position. Dullness is usually heard over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus, which refers to hyperperistalsis, is typically heard on auscultation, not percussion. Hyperresonance is present with gaseous distention, not the typical finding when percussing all four quadrants of the abdomen.

3. A home health care nurse is visiting a male African American client who was recently discharged from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications?

• A. The client's grandson
• B. The client's mother
• C. The client's father
• D. The client's son

Correct answer: B

Rationale: In the African American family structure, the woman, especially the mother, often plays a central role in healthcare decisions and maintaining family health. It is essential for the nurse to involve the client's mother in teaching him about his prescribed medications as she may be responsible for his care and treatment decisions. While other family members may also be involved, the African American family is often matrifocal, emphasizing the importance of the mother's role. Therefore, it is crucial for the nurse to ensure the client's mother is present during medication teaching. Choices A, C, and D are incorrect as they do not align with the traditional African American family structure and the role of women in healthcare decisions.

4. A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:

• A. climacteric
• B. menopause
• C. perimenopause
• D. postmenopause

Correct answer: C

Rationale: Perimenopause refers to a period in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. It typically lasts around five years. In the case of the middle-aged woman experiencing irregular menses for six months, she aligns with perimenopause as it involves irregular menstrual cycles, one of the common symptoms during this transitional phase. Climacteric is a term describing the period of life with physiologic changes leading to the end of a woman's reproductive ability but not specifically characterized by irregular menses. Menopause marks the permanent cessation of menses and does not involve the transitional irregularities seen in perimenopause. Postmenopause is the phase after the completion of menopausal changes.

5. A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?

• A. Contacting the registered nurse
• B. Documenting the findings
• C. Wrapping an extra blanket around the infant
• D. Placing the infant in an oxygen tent

Correct answer: B

Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.

Similar Questions