Nursing Elites

1. While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

• A. Optic
• B. Abducens
• C. Olfactory
• D. Hypoglossal

Correct answer: C

Rationale: The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.

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. 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).

4. A client is scheduled to undergo a Papanicolaou (Pap) test in 1 week. Which statement does the nurse make to the client?

• A. 'If you are menstruating, use pads instead of a tampon.'
• B. 'Avoid intercourse for 24 hours before the scheduled examination.'
• C. 'Get a douching kit from the pharmacy and douche 2 hours before the examination.'
• D. 'If you are having a vaginal discharge, obtain a sample of the discharge for inspection.'

Correct answer: B

Rationale: The correct answer is to 'Avoid intercourse for 24 hours before the scheduled examination.' The Pap test is used to screen for cervical cancer. It is not performed during menstruation or if a heavy infectious discharge is present. Before the test, the client should not douche, have intercourse, or insert anything into the vagina within 24 hours. Instructing the client to use pads instead of a tampon when menstruating can interfere with the test results due to the presence of blood. Douching before the exam is discouraged as it can alter the cervical cells' appearance, affecting the test's accuracy. Obtaining a sample of vaginal discharge for inspection is not a standard pre-Pap test instruction and is unnecessary for the test.

5. A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?

• A. Normally heard in the lungs
• B. Hollow sounds heard over the trachea and larynx
• C. Rustling sounds heard over the peripheral lung fields
• D. Abnormal sounds that should not be heard in the lungs

Correct answer: D

Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.

Similar Questions