Nursing Elites

1. A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

• A. Headache
• B. Neck trauma
• C. Sinus infection
• D. Muscle spasms

Correct answer: B

Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.

2. When evaluating a kinetic family drawing, which of the following nursing actions is most effective?

• A. instructing the child to draw their family doing something
• B. suggesting specific elements to include in the drawing
• C. discouraging the child from discussing the drawing
• D. noting the omission of any family members

Correct answer: D

Rationale: When evaluating a kinetic family drawing, the most effective nursing action is noting the omission of any family members. This approach helps healthcare providers gather crucial information about family dynamics. It is important to pay attention to what the child includes and omits in the drawing, as it can provide insights into underlying emotions and concerns. Choices A, B, and C are not recommended actions for evaluating the drawing. Instructing the child to draw their family doing something or suggesting specific elements to include may bias the drawing, leading to misinterpretations. Discouraging the child from discussing the drawing can impede communication and the understanding of the child's perspective.

3. Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?

• A. single, adult men
• B. single mothers with 2 or 3 children
• C. runaway adolescents
• D. single, adult women

Correct answer: B

Rationale: Single mothers with two or three children are indeed the fastest-growing segment of the homeless population. These families, where the majority of children are under the age of five, make up more than one-third of the homeless population in the United States. While single, adult men have traditionally been the largest group in the homeless population, single mothers with children have been increasing in numbers. Runaway adolescents, although a significant group of homeless children, do not represent the fastest-growing segment of the homeless population. Single, adult women are not specified as the fastest-growing segment.

4. When performing the confrontation test to assess peripheral vision, what action should the nurse take?

• A. Asks the client to identify a small object brought into the visual field
• B. Has the client cover one eye while the nurse covers one eye and slowly advances a target midline between them
• C. Covers one eye, while the client covers the opposite eye, and brings a small object into the visual field
• D. Positions at eye level with the client, covers one eye, and has the client cover the opposite eye, then brings a small object into the visual field

Correct answer: D

Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits. Choices A, B, and C are incorrect. Choice A pertains to testing color vision, which is not part of the confrontation test. Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test. Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.

5. When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?

• A. The nurse speaks loudly.
• B. The nurse allows additional time after each instruction to allow the client to process.
• C. The nurse provides supplemental written resources.
• D. The nurse breaks up the education into multiple shorter sessions.

Correct answer: A

Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.

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