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. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?

• A. Discomfort
• B. Deficit
• C. Feeding
• D. Fractured wrists

Correct answer: D

Rationale: The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor. Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.

3. What is the MOST ACCURATE statement regarding the ESR test?

• A. The results are diagnostic for certain conditions.
• B. Abnormal results are indicative of a potentially fatal illness.
• C. Abnormal results should be followed by additional testing.
• D. Results are reported in millimeters per hour.

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

4. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?

• A. Avoid palpating reportedly “tender” areas as this may cause pain.
• B. Palpate tender areas quickly to minimize patient discomfort.
• C. Initiate the assessment with deep palpation while encouraging the patient to relax and take deep breaths.
• D. Begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch.

Correct answer: D

Rationale: The correct approach is to begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch. This allows the nurse to first assess surface features before proceeding to deeper palpation. Starting with light palpation also helps the patient become more comfortable with being touched, creating a smoother examination experience. Palpating tender areas quickly, as suggested in choice B, can increase patient discomfort. Deep palpation, as in choice C, is typically performed after light palpation to avoid discomfort and ensure proper assessment. Avoiding palpation of tender areas first, as in choice A, helps prevent causing unnecessary pain and should be done towards the end of the assessment.

5. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

• A. Tell the patient, 'Please remain silent while I count your number of breaths.'
• B. Count respirations at the same time you are counting the pulse rate
• C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
• D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

Similar Questions