Nursing Elites

1. A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?

• A. Assessing visual acuity
• B. Inspecting the eyelids for ptosis
• C. Assessing pupil constriction
• D. Assessing ocular movements

Correct answer: A

Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.

2. A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, the nurse tells the group that infants have which developmental need?

• A. Must have needs ignored for short periods to develop a healthy personality
• B. Need to rely on the fact that their needs will be met
• C. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs
• D. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality

Correct answer: B

Rationale: According to Erikson's theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore, options A, C, and D are incorrect as they do not align with Erikson's theory that emphasizes the importance of infants trusting that their needs will be met.

3. The LPN is caring for a client newly diagnosed with HIV. Which statement made by the client regarding antiretroviral therapy (ART) would require correction from the nurse?

• A. "If I start ART and use condoms, I'm less likely to transmit HIV to my partner."?
• B. "I can still use ART even though I am Hepatitis C positive."?
• C. "I will need to be on ART indefinitely."?
• D. "I know I will need to come back for blood draws so that I can begin ART when my CD4 count is over 1,000 cells/mm3."?

Correct answer: D

Rationale: The correct answer is the statement, "I know I will need to come back for blood draws so that I can begin ART when my CD4 count is over 1,000 cells/mm3."? This statement would require correction from the nurse because initiating ART when the CD4 count is over 1,000 cells/mm3 is not supported by guidelines. The World Health Organization (WHO) recommends making treatment a priority for those with a CD4 count of ?350 cells/mm3, as early intervention can help delay disease progression. Therefore, waiting for a CD4 count of over 1,000 cells/mm3 is not in line with current recommendations. Choice A is correct, as studies have shown that using condoms along with ART can significantly reduce the risk of HIV transmission to sexual partners. Choice B is also correct because being Hepatitis C positive does not contraindicate the use of ART. Choice C is correct as well, as ART is typically needed indefinitely to maintain viral suppression and manage HIV. Therefore, the only statement that would require correction is Choice D.

4. The nurse, assisting with data collection of the abdomen, inspects the client’s abdomen. Which assessment technique should the nurse perform next?

• A. Percussion
• B. Auscultation
• C. Light palpation
• D. Deep palpation

Correct answer: B

Rationale: The correct answer is auscultation. The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are normally performed in this order. However, in the abdominal examination, auscultation is performed after inspection and before palpation and percussion. This order is specific to the abdomen because palpation and percussion can increase peristalsis, leading to a false interpretation of bowel sounds. Therefore, auscultation is performed before palpation and percussion in abdominal assessments to ensure accurate bowel sound assessment. Percussion and palpation are performed after auscultation in abdominal assessments. Choices A, C, and D are incorrect as auscultation is the next assessment technique to perform after inspection in abdominal assessments, followed by palpation and percussion.

5. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

• A. maintaining adequate tissue perfusion
• B. demonstrating behaviors that reduce fears
• C. restored body integrity
• D. remaining free of infection

Correct answer: C

Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.

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