Nursing Elites

1. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

2. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

• A. A report of 10 pounds weight loss in the last month
• B. A comment by the client 'I just can't sit still.'
• C. The appearance of eyeballs that appear to 'pop' out of the client's eye sockets
• D. A report of the sudden onset of irritability in the past 2 weeks

Correct answer: C

Rationale: The appearance of eyeballs that appear to 'pop' out of the client's eye sockets, known as exophthalmos, requires quick intervention as it is a severe symptom of Graves' disease. Exophthalmos can indicate an acute condition and may lead to serious complications such as optic nerve damage or corneal ulceration. Weight loss, restlessness, and irritability are common manifestations of hyperthyroidism but do not pose immediate risks compared to the ocular complications associated with exophthalmos.

3. The healthcare provider is assessing a client with suspected tuberculosis. Which symptom would be most concerning?

• A. Night sweats
• B. Weight loss
• C. Cough with bloody sputum
• D. Fatigue

Correct answer: C

Rationale: Cough with bloody sputum is a hallmark symptom of tuberculosis and is highly concerning as it indicates active disease. Hemoptysis (coughing up blood) is associated with tuberculosis infection in the lungs. While night sweats and weight loss are common symptoms of tuberculosis, they are less specific than coughing with bloody sputum. Fatigue is a nonspecific symptom that can be present in various conditions and is not specific to tuberculosis.

4. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?

• A. Roof of mouth, gums, and inside cheeks
• B. Chewing and inner tooth surfaces
• C. Outer tooth surfaces
• D. Tongue

Correct answer: C

Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.

5. Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?

• A. Risk for aspiration
• B. Impaired physical mobility
• C. Disturbed sensory perception
• D. Interrupted family processes

Correct answer: A

Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.

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