Nursing Elites

1. A nurse assisting with data collection is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?

• A. Gurgling sounds
• B. Hypoactive sounds
• C. Low-pitched sounds
• D. An absence of sounds

Correct answer: A

Rationale: Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly between five and 30 times a minute. In this scenario, since the client ate lunch just 45 minutes ago, the nurse would expect to note gurgling sounds as normal bowel activity. Hypoactive sounds (low-pitched) or an absence of sounds are usually associated with conditions such as abdominal surgery or inflammation of the peritoneum, not with recent food intake. Therefore, the correct answer is gurgling sounds, indicating normal bowel activity following a recent meal.

2. A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips in which location?

• A. Behind the knee
• B. Lateral to the extensor tendon of the big toe
• C. In the groove between the malleolus and the Achilles tendon
• D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines

Correct answer: B

Rationale: The correct location to palpate the dorsalis pedis pulse is lateral to and parallel with the extensor tendon of the big toe. Choices A, C, and D describe the locations for other pulses - popliteal, posterior tibial, and femoral artery respectively. The popliteal pulse is found behind the knee, the posterior tibial pulse is located in the groove between the malleolus and the Achilles tendon, and the femoral artery is situated below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.

3. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetic Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct answer is to ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. Assessment is the first step in helping the client establish a suitable diet for disease prevention. By understanding the client's current dietary habits, the nurse can tailor recommendations based on the approved dietary guidelines from the American Diabetic Association and the American Heart Association. Providing a high-protein diet plan without assessing the client's current diet may not align with her cultural preferences or health goals. While educating the client on risk factors for heart disease and diabetes is essential, it is not the initial step in developing a personalized dietary plan.

4. When should rehabilitation services begin?

• A. when the client enters the health care system.
• B. after the client requests rehabilitation services.
• C. after the client's physical condition stabilizes.
• D. when the client is discharged from the hospital.

Correct answer: A

Rationale: Rehabilitation services should begin when the client enters the health care system to ensure early intervention and optimal outcomes. Initiating rehabilitation early can prevent complications, maximize recovery potential, and improve overall health outcomes. Choice B is incorrect because delaying rehabilitation until the client requests it may result in missed opportunities for timely intervention. Choice C is incorrect as waiting for the client's physical condition to stabilize can lead to unnecessary delays in starting the rehabilitation process, potentially slowing down recovery progress. Choice D is incorrect because starting rehabilitation only after discharge can hinder the recovery process by missing out on crucial early stages of intervention and support.

5. A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?

• A. At the onset of menstruation
• B. Every month during ovulation
• C. Weekly, at the same time of day
• D. One week after menstruation begins

Correct answer: D

Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.

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