Nursing Elites

1. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

• A. Confirm the medical diagnosis.
• B. Make accurate nursing diagnoses.
• C. Identify any hereditary traits related to the epilepsy.
• D. Determine what the client believes has caused the epilepsy.

Correct answer: D

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

2. When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?

• A. Robert Peck
• B. Erik Erikson
• C. Sigmund Freud
• D. Jean Piaget

Correct answer: B

Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.

3. When evaluating a kinetic family drawing, which of the following nursing actions is most effective?

• A. instructing the child to draw their family doing something
• B. suggesting specific elements to include in the drawing
• C. discouraging the child from discussing the drawing
• D. noting the omission of any family members

Correct answer: D

Rationale: When evaluating a kinetic family drawing, the most effective nursing action is noting the omission of any family members. This approach helps healthcare providers gather crucial information about family dynamics. It is important to pay attention to what the child includes and omits in the drawing, as it can provide insights into underlying emotions and concerns. Choices A, B, and C are not recommended actions for evaluating the drawing. Instructing the child to draw their family doing something or suggesting specific elements to include may bias the drawing, leading to misinterpretations. Discouraging the child from discussing the drawing can impede communication and the understanding of the child's perspective.

4. A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?

• A. Dull sounds
• B. Hyperresonance sounds
• C. Hypoactive bowel sounds
• D. An absence of bowel sounds

Correct answer: A

Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.

5. Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?

• A. intrauterine device (IUD)
• B. Norplant
• C. oral contraceptives
• D. vaginal sponge

Correct answer: D

Rationale: The correct answer is the vaginal sponge. The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs, as well as reducing the risk of pregnancy. Intrauterine devices (IUDs), Norplant, and oral contraceptives can prevent pregnancy but not the transmission of HIV and STDs. Clients using the contraceptive methods in Choices A, B, and C should be counseled to use a chemical or barrier contraceptive to decrease the transmission of HIV or STDs.

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