Nursing Elites

1. A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider?

• A. "If I go from a very bright room to a very dark room, I have some trouble adjusting."
• B. "I have to hold my newspaper farther and farther away from me when I read."
• C. "I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me."
• D. "It looks like I have a blank spot in the middle of what I'm trying to see."

Correct answer: D

Rationale: The correct answer is "It looks like I have a blank spot in the middle of what I'm trying to see." Seeing blank spots in the middle of an object is a sign of central vision loss, which is a symptom of macular degeneration. Macular degeneration is a serious condition that requires immediate discussion with a healthcare provider to prevent further vision loss. Choice A, mentioning difficulty adjusting between bright and dark rooms, is a common issue related to changes in lighting and not a cause for immediate concern. Choice B, having to hold objects farther away when reading, is indicative of presbyopia, a normal age-related change in vision. Choice C, experiencing slight changes in color perception, is also a common age-related change and not an urgent issue that necessitates immediate discussion with a healthcare provider.

2. A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? What position should the nurse encourage the mother to assume?

• A. Prone
• B. Standing
• C. Supine
• D. Hands and knees

Correct answer: D

Rationale: During back labor, when the back of the fetal head puts pressure on the woman's sacral promontory, the hands-and-knees position is encouraged. This position helps the fetus move away from the sacral promontory, reducing back pain and enhancing the internal-rotation mechanism of labor. A prone position would be difficult for the woman to assume and not helpful in relieving back discomfort. The supine position is risky due to supine hypotension, while standing may increase pressure, worsening backache.

3. Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?

• A. intrauterine device (IUD)
• B. Norplant
• C. oral contraceptives
• D. vaginal sponge

Correct answer: D

Rationale: The correct answer is the vaginal sponge. The vaginal sponge, when used with foam or jelly contraception, acts as a barrier method that can reduce the transmission of HIV and other STDs, in addition to preventing pregnancy. In contrast, IUDs, Norplant, and oral contraceptives are effective in preventing pregnancy but do not provide protection against the transmission of HIV and STDs. IUDs prevent pregnancy by affecting sperm movement and survival, Norplant releases hormones to prevent ovulation, and oral contraceptives work by inhibiting ovulation. However, these methods do not create a physical barrier against HIV and STD transmission. It is important to counsel clients using methods like IUDs, Norplant, and oral contraceptives to also use chemical or barrier contraceptives to lower the risk of HIV or STD transmission.

4. Which of the following vaccines contains a live virus?

• A. varicella
• B. IPV
• C. DTaP
• D. hepatitis B

Correct answer: A

Rationale: The correct answer is varicella. Varicella vaccine contains a live, weakened form of the varicella-zoster virus. Choice B, IPV (inactivated poliovirus vaccine), is an inactivated vaccine, not a live virus vaccine. Choices C and D, DTaP (diphtheria, tetanus, and acellular pertussis vaccine) and hepatitis B vaccine, respectively, do not contain live viruses. Varicella is the only live virus vaccine among the options.

5. Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus?

• A. At the level of the umbilicus
• B. Two centimeters above the umbilicus
• C. Midway between the symphysis pubis and umbilicus
• D. In the pelvic cavity

Correct answer: C

Rationale: The correct answer is midway between the symphysis pubis and the umbilicus. Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus can be palpated at this location but then rises to a level just above the umbilicus before sinking to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus starts descending gradually. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Choices A and B are incorrect as the fundus is not initially at the level of the umbilicus or 2 centimeters above it. Choice D is also incorrect as the fundus does not remain in the pelvic cavity immediately after delivery.

Similar Questions