Nursing Elites

1. When testing the function of the oculomotor, trochlear, and abducens nerves, which parameter does a nurse check to determine their function?

• A. Tongue symmetry
• B. Eye movements
• C. Facial symmetry
• D. Corneal reflex

Correct answer: B

Rationale: The correct answer is B: Eye movements. When assessing the oculomotor, trochlear, and abducens nerves, evaluating eye movements is crucial. This assessment includes checking the pupils for size, regularity, equality, light reactions, accommodation, and extraocular movements in various gaze positions. Tongue symmetry is primarily used to evaluate cranial nerve XII (hypoglossal nerve) function. Facial symmetry is a key indicator of cranial nerve VII (facial nerve) function. The corneal reflex assesses sensory afferents in cranial nerve V (trigeminal nerve) and motor efferents in cranial nerve VII (facial nerve).

2. A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?

• A. Immunizations may be started at any age.
• B. The recommended immunization schedule should be followed.
• C. If a primary series of immunizations is interrupted, it can be continued.
• D. Delaying the start of vaccines does not increase the risk of reaction.

Correct answer: A

Rationale: The correct answer is 'Immunizations may be started at any age.' While there is a recommended immunization schedule, immunizations can be initiated at any age. It is essential to emphasize the flexibility in starting immunizations. The statement 'The recommended immunization schedule should be followed' is too rigid; while recommended, there is flexibility in initiation. Choice C is correct as an interrupted series can be continued without restarting. The statement 'Delaying the start of vaccines does not increase the risk of reaction' is correct. Delaying does not increase the risk of reaction; in fact, it is important to start immunizations to protect the child and the community.

3. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

• A. administering immune globulin intravenously
• B. assessing the extremities for edema, redness, and desquamation every 8 hours
• C. explaining progression of the disease to the client and their family
• D. assessing heart sounds and rhythm

Correct answer: C

Rationale: Educating the client and their family about the progression of Kawasaki disease is crucial for promoting a positive body image. By explaining when symptoms are expected to improve and resolve, the client and family can better understand that there will be no permanent disruption in physical appearance that could negatively impact body image. Administering immune globulin intravenously is a treatment for Kawasaki disease but does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly address body image concerns. Assessing heart sounds and rhythm is essential for evaluating cardiac effects of Kawasaki disease but is not the most direct measure for promoting a positive body image.

4. If Ms. Barrett's distance vision is 20/30, which of the following statements is true?

• A. The client can read from 20' what a person with normal vision can read at 30'.
• B. The client can read from 30' what a person with normal vision can read at 20'.
• C. The client can read the entire chart from 30'.
• D. The client can read the chart from 20' with the left eye and from 30' with the right eye.

Correct answer: A

Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.

5. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

• A. Risk for Self-Harm
• B. Body Image Disturbance
• C. Ineffective Role Performance
• D. Powerlessness

Correct answer: B

Rationale: The correct answer is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and completeness related to infertility, indicating a disturbance in body image perception. 'Risk for Self-Harm' is not the best choice as there is no indication of immediate self-harm. 'Ineffective Role Performance' is less appropriate since the statement does not directly relate to a disruption in the parent's role. 'Powerlessness' could be considered if the client expressed feelings of powerlessness specifically related to the infertility issue.

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