Nursing Elites

1. A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?

• A. Is something wrong with the bath water?
• B. Just calm down, we'll finish your bath soon.
• C. Are you trying to tell me something?
• D. Shall I turn on the television?

Correct answer: A

Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.

2. In which situation would the nurse use bimanual palpation technique?

• A. Palpating the thorax of an infant
• B. Palpating the kidneys and uterus
• C. Assessing pulsations and vibrations
• D. Assessing the presence of tenderness and pain

Correct answer: B

Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.

3. An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?

• A. Foods that are "hot"? or "yang"?
• B. Readings and Eastern medicine meditations
• C. High doses of medicines believed to be "cold"?
• D. No treatment because diarrhea is an expected part of life.

Correct answer: A

Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold. Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.

4. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?

• A. Perform nursing activities throughout the entire shift
• B. Assess for signs of increased muscle tone
• C. Minimize environmental noise
• D. Teach clients to perform the Valsalva maneuver

Correct answer: C

Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.

5. The healthcare professional notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

• A. Yield a falsely low blood pressure
• B. Yield a falsely high blood pressure
• C. Be the same, regardless of cuff size
• D. Vary as a result of the technique of the person performing the assessment

Correct answer: B

Rationale: Using a cuff that is too narrow for an obese patient would likely yield a falsely high blood pressure reading. This occurs because the standard cuff is too small for the arm's circumference, requiring more pressure to compress the artery. A tight cuff can lead to inaccurate and elevated blood pressure readings. Choices A, C, and D are incorrect because using an improperly sized cuff would not yield a falsely low blood pressure, the blood pressure reading does vary with cuff size, and the technique of the person performing the assessment is not the primary factor affecting the reading in this situation.

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