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. When assessing the health-related physical fitness of a client as part of a health assessment, what aspect should be the focus?

• A. agility
• B. speed
• C. body composition
• D. risk factors

Correct answer: D

Rationale: When assessing the health-related physical fitness of a client, the primary focus should be on identifying risk factors that could predispose the client to illness or injury. Risk factors are crucial in determining an individual's overall health status and potential health outcomes. While agility, speed, and body composition are important components of physical fitness assessments, they are not the primary focus when assessing health-related physical fitness from a holistic perspective. Therefore, the correct choice is 'risk factors.'

3. When preparing to listen to a client's breath sounds, what technique should a nurse use?

• A. Ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap.
• B. Listen to the right lung first, then the left lung, moving from top to bottom systematically.
• C. Ask the client to take deep breaths through the mouth.
• D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest.

Correct answer: D

Rationale: When preparing to listen to a client's breath sounds, a nurse should ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little more deeply than usual but to stop if feeling dizzy. The nurse should use the flat diaphragm end-piece of the stethoscope, holding it firmly on the chest wall. By using the diaphragm, the nurse can listen for at least one full respiration in each location, moving from side to side to compare sounds. This technique ensures a systematic and thorough assessment of lung sounds. Choice A is correct as it includes the proper positioning of the client and specifies the use of the diaphragm of the stethoscope. Choice B is incorrect as both lungs should be auscultated systematically, starting from the top and moving down. Choice C is incorrect as deep breaths, not shallow ones, are recommended for an accurate assessment of breath sounds.

4. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?

• A. Firm pressure
• B. Pain behind the eyes
• C. Pain during palpation
• D. Pressure producing an acute headache

Correct answer: A

Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.

5. Which of the following would likely not impede learning?

• A. a client who took Ambien® an hour ago
• B. a bipolar client currently in a manic phase
• C. a client who states they are not interested
• D. a client with dysphagia

Correct answer: C

Rationale: The correct answer is a client who states they are not interested. While lack of interest can hinder learning motivation, it is not a physical or mental barrier that directly impacts the learning process. On the other hand, a client who took Ambien® an hour ago may experience drowsiness or impaired cognitive function, affecting their ability to learn. A bipolar client in a manic phase may exhibit symptoms such as racing thoughts, distractibility, and impulsivity, making it challenging for them to focus and engage in the learning process. A client with dysphagia may have difficulty swallowing, which can interfere with their ability to take oral medications or participate in activities that involve swallowing.

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