Nursing Elites

1. A nurse is assisting in the admission of a young adult female Korean exchange student with acute abdominal pain. When asked about her sexual activity, she looks away. What should the nurse do?

• A. Omit this question from the assessment form
• B. Ask her if she would like an interpreter present to assist with communication
• C. Reword the question to ensure the client's understanding
• D. Watch the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to a different question can help gauge her comfort level and understanding, which is essential in culturally sensitive care. By watching her response to a different question, the nurse can assess if the discomfort is related to the specific question or a broader issue. Omitting the question may result in missing crucial information. Asking about an interpreter assumes that the language barrier is the only issue, which may not be the case. Rewording the question may not address the underlying discomfort and could still lead to misinterpretation.

2. Which type of cell is responsible for producing antibodies in the immune system?

• A. B lymphocytes
• B. T lymphocytes
• C. Macrophages
• D. Neutrophils

Correct answer: A

Rationale: The correct answer is A: B lymphocytes. B lymphocytes (B cells) are a crucial part of the adaptive immune system. They produce antibodies, which are proteins that specifically target and neutralize pathogens such as bacteria and viruses. T lymphocytes (choice B) are involved in cell-mediated immunity rather than antibody production. Macrophages (choice C) are phagocytic cells that engulf and digest pathogens but do not produce antibodies. Neutrophils (choice D) are a type of white blood cell that primarily function in the innate immune response by phagocytosing pathogens.

3. What disorder closely matches Suzy's symptoms?

• A. Antisocial personality disorder
• B. Borderline personality disorder
• C. Schizoid personality disorder
• D. Dissociative Identity Disorder

Correct answer: B

Rationale: Suzy's symptoms are characteristic of Borderline Personality Disorder (BPD). BPD includes instability in relationships, self-image, and emotions, as well as impulsivity and self-harm. Choice A, Antisocial personality disorder, is characterized by a disregard for others' rights and lack of empathy, which does not align with Suzy's symptoms. Schizoid personality disorder, choice C, is characterized by a lack of interest in social relationships, which is not a prominent feature in Suzy's case. Dissociative Identity Disorder, choice D, involves the presence of two or more distinct identities or personality states, which is not reflected in Suzy's symptoms.

4. You have a patient who has just had a diagnostic arthroscopy. You are instructing him about what to do when he gets home. Which of the following would you NOT instruct him to do?

• A. Resume normal activities within 12 hours so as to help reduce the swelling
• B. Elevate the extremity for 24 – 48 hours
• C. Apply ice to the area involved intermittently
• D. Report severe pain to the physician immediately

Correct answer: A

Rationale: Patients should rest and avoid normal activities for a short period after arthroscopy to allow healing and prevent swelling, which could worsen with early activity. Elevation and icing are recommended post-procedure to reduce swelling and pain. Instructing the patient to resume normal activities within 12 hours could lead to increased swelling and delayed healing. Reporting severe pain is crucial as it could indicate a complication. Therefore, the correct instruction is not to resume normal activities immediately after arthroscopy.

5. When assisting an older male client recovering from a stroke to ambulate with a cane, where should the nurse place the cane in relation to the client's body?

• A. In front of the body to lean on while stepping forward
• B. On the opposite side of the affected extremity
• C. Approximately one foot away from the body to stabilize balance
• D. On the same side as the affected extremity

Correct answer: B

Rationale: The correct answer is B: 'On the opposite side of the affected extremity.' Placing the cane on the opposite side of the affected extremity provides maximum support and stability during ambulation for a client recovering from a stroke. This positioning helps to offload weight from the affected side and improves balance. Choice A is incorrect because placing the cane in front of the body can lead to incorrect weight distribution and instability. Choice C is incorrect as placing the cane one foot away from the body may not provide adequate support and can compromise balance. Choice D is incorrect as placing the cane on the same side as the affected extremity does not offer the necessary balance and support needed for safe ambulation.

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