Nursing Elites

1. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

• A. Obtain the blood pressure under the same conditions each time
• B. Use a different arm for each measurement
• C. Measure the blood pressure while the client is standing
• D. Take multiple readings at different times of the day

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

2. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action

• A. May result in charges of unlawful seclusion and restraint
• B. Leaves the nurse vulnerable to charges of assault and battery
• C. Was appropriate given the client's history of violence
• D. Was necessary to maintain the therapeutic milieu of the unit

Correct answer: A

Rationale: Seclusion should only be used when necessary and with proper documentation; otherwise, it may be considered unlawful. Placing a client in seclusion without a clear indication or proper documentation could lead to legal ramifications, making choice A the correct answer. Choice B is incorrect because assault and battery do not apply in this scenario. Choice C is incorrect as there is no mention of the client posing an imminent threat due to a history of violence. Choice D is incorrect as seclusion should not be used solely to maintain the therapeutic milieu but rather for the safety of the client and others.

3. When caring for a client prescribed a blood transfusion that parents refuse due to religious beliefs, what should the nurse do?

• A. Examine personal values about the issue.
• B. Proceed with the transfusion if medically necessary.
• C. Refer the issue to the ethics committee.
• D. Administer the blood transfusion without informing the parents.

Correct answer: A

Rationale: When faced with a situation where parents refuse a prescribed treatment due to religious beliefs, the nurse should first examine personal values, understand the client's or family’s beliefs, and respect their rights. Proceeding with the transfusion against the parents' wishes without exploring alternatives or understanding their perspective would violate the principle of respect for autonomy and could damage the therapeutic relationship. Referring the issue to the ethics committee should be considered if a resolution cannot be reached through open communication and negotiation with the family.

4. A healthcare provider is assessing a client's ability to balance. Which of the following actions is appropriate when the healthcare provider conducts a Romberg test?

• A. Ask the client to extend their arms in front of their body.
• B. Ask the client to walk in a straight line heel to toe.
• C. Have the client stand with their feet together.
• D. Have the client place their hands on their hips.

Correct answer: C

Rationale: The Romberg test is a neurological test that assesses proprioception and balance. To perform this test, the client is asked to stand with their feet together and arms at their sides while closing their eyes. By removing visual input, the test challenges the vestibular and proprioceptive systems. Choices A, B, and D are incorrect because they do not align with the proper procedure for conducting the Romberg test. Extending arms in front, walking heel to toe, or placing hands on hips are not part of the Romberg test protocol and may introduce variables that could affect the assessment of balance.

5. During a skin assessment, a client expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?

• A. A mole with an asymmetrical appearance.
• B. A mole with a regular border.
• C. A mole that is the same color throughout.
• D. A mole that is smaller than 6mm in diameter.

Correct answer: A

Rationale: The correct answer is A: A mole with an asymmetrical appearance. Asymmetry is a key characteristic of potential skin malignancy. An asymmetrical mole does not have a uniform shape when divided in half. This irregularity raises suspicion for skin cancer. Choices B, C, and D are incorrect. A mole with a regular border (B) is more likely to be benign. A mole that is the same color throughout (C) is also a feature commonly seen in benign moles. Additionally, a mole smaller than 6mm in diameter (D) is not necessarily indicative of malignancy, as some melanomas can be smaller or larger than this size.

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