Nursing Elites

1. A female client asks a nurse about the advantages of using a female condom. The nurse discusses which advantage with the client?

• A. That it offers protection against sexually transmitted infections (STIs)
• B. That it cannot be used along with a male condom
• C. That it does not have to be discarded after use and can be used several times before a new one must be obtained
• D. That it is 100% effective in preventing pregnancy

Correct answer: A

Rationale: The correct answer is that the female condom offers protection against sexually transmitted infections (STIs). Unlike the male condom, the female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. It is used once and then discarded, making choice C incorrect. Female and male condoms should not be used together, so choice B is incorrect. Additionally, no contraceptive method is 100% effective in preventing pregnancy, making choice D incorrect.

2. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?

• A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
• B. taking a cool shower and drinking a hot cup of tea
• C. watching TV nightly until midnight
• D. getting a back rub and drinking a glass of warm milk

Correct answer: D

Rationale: The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.

3. Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?

• A. Rectus femoris muscle
• B. Deltoid muscle
• C. Gluteal muscle
• D. Vastus lateralis muscle

Correct answer: D

Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.

4. A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?

• A. Asking the client to stick out his or her tongue and watching for tremors
• B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
• C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
• D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

Correct answer: D

Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.

5. A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?

• A. Emergency
• B. Follow-up
• C. Complete (total)
• D. Problem-centered

Correct answer: B

Rationale: The correct answer is 'Follow-up.' A follow-up database is used to assess the status of an identified problem at regular intervals. An emergency database is for urgent data collection during life-saving measures. A complete database involves a full health history and physical examination. A problem-centered (episodic) database focuses on a limited or short-term issue, typically centered around one problem or body system.

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