Nursing Elites

1. When inspecting the ears for cerumen impaction, the nurse checks for which finding?

• A. Redness and swelling of the tympanic membrane
• B. An external auditory canal that is longer than normal
• C. The presence of edema in the external auditory canal
• D. A yellowish or brownish waxy material in the external auditory canal

Correct answer: D

Rationale: When inspecting the ears for cerumen impaction, the nurse should look for a yellowish or brownish waxy material in the external auditory canal. Cerumen, also known as ear wax, is a secretion that can become impacted due to various reasons. It is produced by the vestigial apocrine sweat glands in the external ear canal. Cerumen may partially obscure the eardrum or totally occlude the ear canal. The other options, redness and swelling of the tympanic membrane, an external auditory canal that is longer than normal, and the presence of edema in the external auditory canal, are not indicative findings of cerumen impaction.

2. A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm, and the color is pink. What action should the nurse perform next to prevent ischemia?

• A. Notify the physician immediately
• B. Obtain a Doppler device to check for pulses, and notify the physician if they are still absent
• C. Wait 30 minutes and recheck the pulses
• D. Document the finding

Correct answer: B

Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial pulses can be difficult to assess and might need to be verified with a Doppler device. Since the client just had surgery with a risk of arterial insufficiency, close monitoring is crucial. If pulses are not palpable, it indicates an emergent situation requiring immediate physician notification. Waiting 30 minutes before reassessment could lead to foot ischemia. While documenting findings is essential, it should follow pulse confirmation or necessary interventions to ensure the client's foot viability.

3. A sexually active married couple, discussing birth control methods with the nurse, expresses the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest?

• A. Diaphragm
• B. Sterilization
• C. Male condom
• D. Spermicide

Correct answer: B

Rationale: In this scenario, since the couple has indicated that their family-planning goals have been met, a permanent method of contraception like sterilization would be most suitable. Sterilization offers long-term effectiveness and convenience once the decision to stop having children is made. Options like the diaphragm, male condom, or spermicide are more suitable for temporary contraception or when the family-planning goals have not yet been achieved. Therefore, the correct answer is sterilization, as it aligns with the couple's need for a convenient and permanent birth control method.

4. A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?

• A. Allow the toddler to play with other children in the nursing unit playroom.
• B. Spend as much time as possible with the toddler.
• C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room.
• D. Keep hospital routines as similar as possible to those at home.

Correct answer: D

Rationale: The best action for the nurse to take to help a hospitalized toddler maintain a sense of control and security and ease feelings of helplessness and fear is to keep hospital routines as similar as possible to those at home. By incorporating the toddler's usual rituals and routines from home into nursing care activities, the nurse can reduce the stress of hospitalization. This approach gives the toddler a sense of familiarity, control, and security, which can alleviate feelings of helplessness and fear. Allowing the toddler to play with other children in the nursing unit playroom and selecting toys are beneficial activities, but maintaining hospital routines similar to those at home is the most effective way to support the toddler's emotional well-being during hospitalization.

5. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

• A. immobility
• B. altered growth and development
• C. hemarthrosis
• D. altered family processes

Correct answer: D

Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.

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