Nursing Elites

1. A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?

• A. Stethoscope
• B. Doppler transducer
• C. Fetoscope
• D. Pulse oximetry on the client and a fetoscope

Correct answer: B

Rationale: To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.

2. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?

• A. Iris
• B. Cornea
• C. Optic disc
• D. Conjunctiva

Correct answer: C

Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.

3. The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness?

• A. The child no longer has temper tantrums.
• B. The child can remove his or her own clothing.
• C. The child has been walking for 2 years.
• D. The child can eat using a fork and knife.

Correct answer: B

Rationale: Signs of physical readiness for toilet training include the child's ability to remove his or her own clothing. This ability indicates the child has developed the necessary fine motor skills to manage clothing during toilet training. The other choices are incorrect because temper tantrums, walking for a specific period, and using utensils are not indicators of physical readiness for toilet training.

4. The greatest time savers when planning client care include all of the following except:

• A. reacting to the crisis of the moment
• B. setting goals
• C. planning
• D. specifying priorities

Correct answer: A

Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, specifying priorities, planning tasks, delegating where appropriate, reassessment, and ongoing evaluation of needs. Reacting to the crisis of the moment is not a time-saving strategy in client care planning; it can lead to inefficiency, lack of focus, and potentially missing important priority items. Therefore, the correct answer is 'reacting to the crisis of the moment.' Choices B, C, and D are essential components for effective client care planning as they help in organizing and prioritizing tasks, setting objectives, and ensuring a structured approach to care delivery.

5. A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:

• A. assessment.
• B. crisis intervention.
• C. empathetic concern.
• D. unwarranted intrusion

Correct answer: B

Rationale: Crisis intervention is the correct choice. Counseling by a nurse specialist after a traumatic event like rape falls under the Crisis Intervention Model. This approach aims to provide immediate support to individuals facing a crisis to enhance coping mechanisms. In this scenario, the nurse specialist is offering specialized care tailored to rape victims, helping the client navigate through the emotional aftermath of the traumatic experience. Choices A, C, and D are incorrect: A is not the correct answer as the nurse specialist is providing emotional support rather than conducting an assessment; C, while important, does not fully capture the specialized intervention being provided; and D is inaccurate as the nurse specialist's intervention is warranted and essential for the victim's well-being.

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