Nursing Elites

1. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?

• A. After menopause, blood pressure readings in women are usually higher than those taken in men.
• B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
• C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
• D. A teenager's blood pressure reading may be lower than that of an adult.

Correct answer: B

Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.

2. When assessing the force or strength of a pulse, what would the nurse recall about the pulse?

• A. Is a reflection of the heart's stroke volume
• B. Typically recorded on a 0- to 3-point scale
• C. Demonstrates elasticity of the blood vessel wall
• D. Reflects the blood volume in the arteries during diastole

Correct answer: A

Rationale: When assessing the force or strength of a pulse, the nurse should recall that it is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta, causing arterial walls to flare and generate a pressure wave felt as the pulse in the periphery. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not demonstrate the elasticity of blood vessel walls or reflect the blood volume in the arteries during diastole. Therefore, choices B, C, and D are incorrect.

3. Surgical asepsis is being performed when:

• A. wiping down exam tables with bleach
• B. sterilizing instruments
• C. changing table paper
• D. wearing gloves when performing injections

Correct answer: B

Rationale: Surgical asepsis refers to the process of maintaining a sterile environment to prevent the introduction of pathogens to a patient's body. Sterilizing instruments is a crucial aspect of surgical asepsis as it ensures that the instruments used during procedures are free from microorganisms that could cause infections. Wiping down exam tables with bleach may help in cleaning and disinfecting surfaces but does not pertain directly to maintaining a sterile field. Changing table paper is important for cleanliness and infection control but is not specifically related to surgical asepsis. Wearing gloves when performing injections is important for standard precautions and preventing the spread of infection but does not encompass the concept of surgical asepsis, which focuses on maintaining a sterile field during invasive procedures.

4. During an examination, the nurse notices that a female patient has a round "moon"? face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?

• A. Gigantism
• B. Acromegaly
• C. Cushing syndrome
• D. Marfan syndrome

Correct answer: C

Rationale: Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and a round, plethoric face (moon face). Excessive catabolism in Cushing syndrome causes muscle wasting, weakness, thin arms and legs, reduced height, and thin, fragile skin with purple abdominal striae, bruising, and acne. Gigantism is characterized by increased height and weight and delayed sexual development, which are not present in the patient. Acromegaly results from excessive growth hormone secretion in adulthood, leading to bone overgrowth in specific areas like the face, head, hands, and feet. Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and distinct features not seen in this patient. The combination of signs described in the question aligns with the clinical presentation of Cushing syndrome.

5. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

• A. Client appears to be depressed, possibly suicidal
• B. Client reports being tired of being ill and wants to die
• C. Client does not want to live any longer and is tired of being ill
• D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

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