Nursing Elites

1. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?

• A. Inform the client that he may experience tingling sensations.
• B. Connect the TENS unit before the client goes to bed for the night.
• C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
• D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.

Correct answer: A

Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.

2. What are Korotkoff sounds?

• A. Sounds noted during diastole.
• B. The result of the vibration of blood against artery walls while blood pressure readings are being taken.
• C. Sounds only noted by skilled cardiologists.
• D. Distinct sounds which are classified into 6 phases.

Correct answer: B

Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated. Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.

3. Which of these specific measurements is the best index of a child's general health?

• A. Body mass index
• B. Height and weight
• C. Head circumference
• D. Chest circumference

Correct answer: B

Rationale: Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status. Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.

4. A patient's body temperature has varied over the last 24 hours from 97.6 degrees F in the morning to 99 degrees F in the evening. The patient is worried that this change in temperature may indicate the beginning of a fever. Which of the following BEST explains this phenomenon?

• A. The patient definitely has a fever in the evening and should be seen by a doctor.
• B. The patient is experiencing changes related to a diurnal rhythm.
• C. The patient is more than likely taking their temperature incorrectly.
• D. The patient is experiencing changes related to fluctuating daily hormones.

Correct answer: B

Rationale: The patient is experiencing changes related to a diurnal rhythm. Diurnal rhythm is the phenomenon of body temperature fluctuating depending on the time of day. Temperatures taken in the morning are typically lower than those taken throughout the rest of the day. Choice A is incorrect because a single elevated temperature reading in the evening does not definitively indicate a fever. Choice C is incorrect as there is no indication of incorrect temperature measurement. Choice D is incorrect as the temperature changes are not related to monthly hormones but rather to the body's natural daily rhythm.

5. When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?

• A. Ask the patient to take deep breaths to relax the abdominal musculature.
• B. Consider this finding as normal and proceed with the abdominal assessment.
• C. Increase the amount of strength used when attempting to percuss over the abdomen.
• D. Decrease the amount of strength used when attempting to percuss over the abdomen.

Correct answer: C

Rationale: When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.

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