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. What procedure examines a portion of the large intestine with an endoscope?

• A. Colposcopy
• B. Sigmoidoscopy
• C. Upper GI
• D. Cardiac catheterization

Correct answer: B

Rationale: Sigmoidoscopy is the correct answer because it specifically examines the sigmoid colon located in the descending colon using an endoscope inserted through the rectum. This procedure captures video and images of the large intestine's lining, helping in the diagnosis of conditions like inflammatory bowel disease or colorectal cancer. Colposcopy, on the other hand, is a procedure for examining the cervix and vagina, not the large intestine. Upper GI involves capturing images of the esophagus and stomach, focusing on the upper gastrointestinal tract, not the large intestine. Cardiac catheterization is a procedure that involves threading a thin instrument through the femoral artery to the heart, used for cardiac interventions and not related to examining the large intestine.

3. A 60-year-old patient has been treated for pneumonia for the past 6 weeks. The patient is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. Which is an appropriate rationale for this patient's weight loss?

• A. Chronic diseases such as hypertension do not usually cause weight loss.
• B. Weight loss is more likely due to underlying medical conditions than unhealthy eating habits.
• C. Unexplained weight loss often accompanies short-term illnesses.
• D. Weight loss is not typically caused by mental health dysfunctions.

Correct answer: C

Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.

4. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

• A. Keep all of the side rails up
• B. Review prescribed medications
• C. Complete the "get up and go"? test
• D. Place the bed in the lowest position

Correct answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.

5. When assessing the force or strength of a pulse, what would the nurse recall about the pulse?

• A. Is a reflection of the heart's stroke volume
• B. Typically recorded on a 0- to 3-point scale
• C. Demonstrates elasticity of the blood vessel wall
• D. Reflects the blood volume in the arteries during diastole

Correct answer: A

Rationale: When assessing the force or strength of a pulse, the nurse should recall that it is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta, causing arterial walls to flare and generate a pressure wave felt as the pulse in the periphery. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not demonstrate the elasticity of blood vessel walls or reflect the blood volume in the arteries during diastole. Therefore, choices B, C, and D are incorrect.

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