Nursing Elites

1. A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. What should be the nurse’s next action?

• A. Document the client’s concern in the medical record.
• B. Report the client’s concern to the health care provider.
• C. Tell the client that sexual dysfunction is not a normal age-related change.
• D. Ask the client about medications he is taking.

Correct answer: Ask the client about medications he is taking.

Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. It is crucial to assess the medications the client is taking as they could be contributing to the reported sexual dysfunction. While documenting the concern and informing the healthcare provider are important steps, the immediate priority is to gather information on the medications that could be impacting the client's sexual function. Therefore, the nurse's next action should be to ask the client about the medications he is taking.

2. During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

• A. 'When was your last gynecological checkup?'
• B. 'Have you been engaging in unprotected sexual intercourse?'
• C. 'Don’t worry about the discharge. Some vaginal discharge is normal.'
• D. 'I need some more information about the discharge. What color is it?'

Correct answer: 'I need some more information about the discharge. What color is it?'

Rationale: If the client reports having vaginal drainage and concerns about a possible STI, it is essential for the nurse to gather more information about the discharge. Asking about the color of the discharge helps in determining its characteristics, which can be crucial in identifying potential causes. The color, consistency, odor, and associated symptoms can provide valuable insights into the underlying issue. Statements A and B are relevant questions but not as immediate or specific to addressing the client's concern about the discharge. Statement C dismisses the client's worries and does not encourage further assessment, which is not appropriate in this context.

3. An assessment of the skull of a normal 10-month-old baby should identify which of the following?

• A. closure of the posterior fontanel.
• B. closure of the anterior fontanel.
• C. overlap of cranial bones.
• D. ossification of the sutures.

Correct answer: closure of the anterior fontanel.

Rationale: The correct answer is the closure of the anterior fontanel. By 10 months of age, the anterior fontanel should be closed. The posterior fontanel should actually close by the age of 2 months, making choice A incorrect. Overlap of cranial bones is not a typical finding in a normal 10-month-old baby's skull, so choice C is incorrect. Ossification of the sutures is an ongoing process in skull development and should not be a definitive indicator at this age, making choice D incorrect.

4. A nurse suspects that a client has a distended bladder. On percussing the client’s bladder, which finding does the nurse expect to note if the bladder is full?

• A. Dull sounds
• B. Hyperresonance sounds
• C. Hypoactive bowel sounds
• D. An absence of bowel sounds

Correct answer: Dull sounds

Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.

5. Client self-determination is the primary focus of:

• A. malpractice insurance.
• B. nursing’s advocacy for clients.
• C. confidentiality.
• D. health care.

Correct answer: nursing’s advocacy for clients.

Rationale: Client self-determination is the primary focus of nursing’s advocacy for clients. Nurses advocate for their clients' right to autonomy and self-determination, ensuring that the clients' preferences and choices are respected. Confidentiality, on the other hand, involves maintaining the privacy of the client and their information. Health care is a broad term encompassing various aspects of medical services. Malpractice insurance is a type of insurance that provides coverage for professionals in case of negligence or malpractice, not directly related to client self-determination.

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