Nursing Elites

1. A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

• A. Check the client's temperature.
• B. Report the findings to the nurse-midwife.
• C. Obtain a sample of the amniotic fluid for laboratory analysis.
• D. Document the findings.

Correct answer: D

Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

2. A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action?

• A. Uses short sentences
• B. Speaks at a normal rate and volume
• C. Uses facial expressions or gestures
• D. Overarticulates words

Correct answer: D

Rationale: The correct answer is 'Overarticulates words.' When communicating with a hearing-impaired client who may rely on lip-reading, it is essential to speak clearly at a normal rate and volume. Overarticulating words can distort lip movements, making it harder for the client to understand. Using short sentences helps in conveying information effectively, allowing the client time to process. While facial expressions and gestures provide additional visual cues that aid in communication, overarticulating words can be counterproductive in this scenario. Therefore, the nursing assistant should avoid overarticulating words to ensure clear and concise communication for the client.

3. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?

• A. Homan sign
• B. Murphy sign
• C. Blumberg sign
• D. McBurney sign

Correct answer: B

Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.

4. A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:

• A. climacteric
• B. menopause
• C. perimenopause
• D. postmenopause

Correct answer: C

Rationale: Perimenopause refers to a period in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. It typically lasts around five years. In the case of the middle-aged woman experiencing irregular menses for six months, she aligns with perimenopause as it involves irregular menstrual cycles, one of the common symptoms during this transitional phase. Climacteric is a term describing the period of life with physiologic changes leading to the end of a woman's reproductive ability but not specifically characterized by irregular menses. Menopause marks the permanent cessation of menses and does not involve the transitional irregularities seen in perimenopause. Postmenopause is the phase after the completion of menopausal changes.

5. A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?

• A. Allow the toddler to play with other children in the nursing unit playroom.
• B. Spend as much time as possible with the toddler.
• C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room.
• D. Keep hospital routines as similar as possible to those at home.

Correct answer: D

Rationale: The best action for the nurse to take to help a hospitalized toddler maintain a sense of control and security and ease feelings of helplessness and fear is to keep hospital routines as similar as possible to those at home. By incorporating the toddler's usual rituals and routines from home into nursing care activities, the nurse can reduce the stress of hospitalization. This approach gives the toddler a sense of familiarity, control, and security, which can alleviate feelings of helplessness and fear. Allowing the toddler to play with other children in the nursing unit playroom and selecting toys are beneficial activities, but maintaining hospital routines similar to those at home is the most effective way to support the toddler's emotional well-being during hospitalization.

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