Nursing Elites

1. When inspecting the client's eyelids for ptosis, the nurse is checking for which abnormality?

• A. Drooping
• B. Pupil dilation
• C. Pupil constriction
• D. Deviation of ocular movements

Correct answer: A

Rationale: When a nurse inspects a client's eyelids for ptosis, they are checking for drooping. Ptosis is a condition characterized by the drooping of the eyelids and can be associated with various disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell's palsy. Pupil dilation and constriction are assessed using a flashlight to check pupillary response. Deviation of ocular movements is evaluated by leading the client's eyes through the six cardinal positions of gaze. Therefore, in this scenario, the correct answer is 'Drooping' as it specifically relates to the abnormality associated with ptosis.

2. The LPN is admitting a client to the unit, and the client has rapidly blinking eyes, a stuck-out tongue, and a distorted posture. Which of these medications is the client most likely taking?

• A. Clozapine
• B. Fluoxetine
• C. Ondansetron
• D. Haloperidol

Correct answer: D

Rationale: The correct answer is Haloperidol. Haloperidol is a first-generation antipsychotic that blocks dopamine receptors and is most likely to cause extrapyramidal symptoms (EPS), such as tardive dyskinesia. Symptoms of tardive dyskinesia include rapid blinking, mouth movements, sticking out the tongue, rapid body movements, and a distorted posture. Haloperidol is associated with a higher risk of EPS compared to other antipsychotic medications like Clozapine. Clozapine is known for having a lower risk of causing EPS. Fluoxetine is a selective serotonin reuptake inhibitor used for depression and anxiety, not typically associated with these movement disorder symptoms. Ondansetron is an antiemetic used to prevent nausea and vomiting, not linked to these extrapyramidal symptoms.

3. What is the primary theory that explains a family's concept of health and illness?

• A. Health Belief Model
• B. Education-School-Completing Factor
• C. Family Health Expert Factor
• D. Disconnected Family Factor

Correct answer: A

Rationale: The correct answer is the Health Belief Model. This model explains a family's concept of health and illness by focusing on readiness factors, perceived susceptibility, and seriousness of health problems, and positive motivation for wellness. The Health Belief Model is widely used in healthcare to understand and predict health behaviors. Choices B, C, and D are incorrect as they do not specifically address how a family perceives health and illness. The Health Belief Model is the most appropriate choice as it is specifically designed to explain individual and family beliefs and behaviors related to health and illness.

4. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:

• A. sprain.
• B. strain.
• C. subluxation.
• D. dislocation.

Correct answer: B

Rationale: The term 'strain' is the correct choice. A strain refers to the excessive stretching of a muscle or tendon, which aligns with a pulled ligament diagnosis. A sprain, on the other hand, involves ligament injury due to twisting motions. 'Subluxation' indicates a partial dislocation of a joint, not a pulled ligament. 'Dislocation' refers to the complete displacement of bones in a joint, which is not the appropriate term for a pulled ligament.

5. A nurse assisting with data collection of the peripheral vascular system performs the Allen test. The nurse understands that this test is used to determine the patency of which blood vessel(s)?

• A. Capillaries
• B. Pedal pulses
• C. Femoral arteries
• D. Radial and ulnar arteries

Correct answer: D

Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client's ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen. Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries. Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot. Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.

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