Nursing Elites

1. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:

• A. Referred pain
• B. Superficial pain
• C. Radiating pain
• D. Precipitating pain

Correct answer: C

Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.

2. The client starting an exercise program will progress to walking a 20-minute mile in one month.

• A. Client will walk quickly three times a day
• B. Client will be able to walk a mile
• C. Client will have no alteration in breathing during the walk
• D. Client will progress to walking a 20-minute mile in one month

Correct answer: D

Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. Choice A lacks specificity and does not mention a target time or goal. Choice B is vague and does not provide a specific target for improvement. Choice C focuses on a negative outcome (no alteration) rather than a positive goal. The correct answer, Choice D, is specific, measurable, and time-bound, making it a suitable outcome statement for a client starting an exercise program.

3. Which of the following items of subjective client data would be documented in the medical record by the nurse?

• A. Client's face is pale
• B. Cervical lymph nodes are palpable
• C. Nursing assistant reports client refused lunch
• D. Client feels nauseated

Correct answer: D

Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.

4. Which of the following statements best describes footdrop?

• A. The foot is permanently fixed in the dorsiflexion position
• B. The foot is permanently fixed in the plantar flexion position
• C. The toes of the foot are permanently fanned
• D. The heel of the foot is permanently rotated outward

Correct answer: B

Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.

5. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

• A. Administer the feeding as ordered
• B. Pull the feeding tube out approximately 3 cm
• C. Flush the feeding tube with 60 cc of water
• D. Contact the physician

Correct answer: A

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

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