Nursing Elites

1. A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?

• A. vitiligo
• B. erythema
• C. cyanosis
• D. chloasma

Correct answer: D

Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes during pregnancy. Vitiligo is characterized by depigmented patches, erythema is redness of the skin due to increased blood flow, and cyanosis is a bluish discoloration due to poor circulation or lack of oxygen, none of which are typical skin-color variations during pregnancy. Therefore, in a pregnant client, the most likely normal skin-color variation to be displayed is chloasma.

2. While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?

• A. Liver enlargement
• B. Ovarian infection
• C. Spleen enlargement
• D. Kidney inflammation

Correct answer: D

Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.

3. Which condition is associated with inadequate intake of vitamin C?

• A. rickets
• B. marasmus
• C. kwashiorkor
• D. scurvy

Correct answer: D

Rationale: Scurvy is indeed associated with inadequate intake of vitamin C. Vitamin C deficiency leads to scurvy, which is characterized by weakness, anemia, gum disease, and skin hemorrhages. Choices A, B, and C are incorrect because rickets is caused by vitamin D deficiency, marasmus is due to severe malnutrition leading to wasting, and kwashiorkor is a form of severe protein-energy malnutrition.

4. A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? What position should the nurse encourage the mother to assume?

• A. Prone
• B. Standing
• C. Supine
• D. Hands and knees

Correct answer: D

Rationale: During back labor, when the back of the fetal head puts pressure on the woman's sacral promontory, the hands-and-knees position is encouraged. This position helps the fetus move away from the sacral promontory, reducing back pain and enhancing the internal-rotation mechanism of labor. A prone position would be difficult for the woman to assume and not helpful in relieving back discomfort. The supine position is risky due to supine hypotension, while standing may increase pressure, worsening backache.

5. An appraisal of self-care practices involves an assessment of:

• A. all diagnostic tests.
• B. home treatment practices, including nurse visits for the sick or disabled.
• C. the family's capability to get health insurance.
• D. caregiving needs and the potential for strain.

Correct answer: D

Rationale: An appraisal of self-care practices focuses on assessing caregiving needs and the potential for strain. This involves evaluating the support system in place for individuals requiring care, the level of strain experienced by caregivers, and the overall impact of caregiving responsibilities on both the caregiver and the care recipient. The other options presented do not directly relate to the assessment of self-care practices. Diagnostic tests, home treatment practices, and the family's capability to obtain health insurance are important aspects of healthcare but do not specifically pertain to the evaluation of self-care practices.

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