Nursing Elites

1. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

• A. Client appears to be depressed, possibly suicidal
• B. Client reports being tired of being ill and wants to die
• C. Client does not want to live any longer and is tired of being ill
• D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

2. The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?

• A. Exercise
• B. Radiation
• C. Metabolism
• D. Food digestion

Correct answer: B

Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.

3. Which of the following vital signs can be expected in a child that is afebrile?

• A. Rectal Temp of 100.9 degrees F.
• B. Oral Temp of 38 degrees C.
• C. Axillary Temp of 98.6 degrees F.
• D. All of the above are incorrect.

Correct answer: C

Rationale: The correct answer is the axillary temperature of 98.6 degrees F. Afebrile means without a fever, and an axillary temperature, which is taken in the armpit, is considered normal at 98.6 degrees F. Choice A is incorrect as a rectal temperature of 100.9 degrees F indicates a fever. Choice B is incorrect as an oral temperature of 38 degrees C is also indicative of a fever. Choice D is incorrect as not all options are wrong; only choices A and B are incorrect for an afebrile child.

4. You see a sign over Mary Jones' bed when you arrive at 7 am to begin your day shift. The sign says, 'NPO'. Ms. Jones is on a regular diet. The patient asks for milk and some crackers. You _____________.

• A. can give her the milk but not the crackers
• B. can give her both the milk and the crackers
• C. can give her the crackers but not the milk
• D. cannot give her anything to eat or drink

Correct answer: D

Rationale: The correct answer is that you cannot give her anything to eat or drink. 'NPO' is the standard abbreviation for 'nothing by mouth,' indicating that the patient should not consume any food or liquids. It is crucial to adhere to this restriction to prevent any potential harm or complications in the patient's condition. Choices A, B, and C are incorrect because 'NPO' clearly specifies that the patient should not have anything to eat or drink, including milk and crackers. Providing these items could lead to adverse effects, so it is essential to follow the 'NPO' directive strictly.

5. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?

• A. Collaborating with the client to establish healthcare goals
• B. Reviewing the client's medical record history
• C. Explaining the purpose of administered medications to the client
• D. Rapidly resetting priorities for client care based on changes in the client's condition

Correct answer: D

Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.

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