Nursing Elites

1. When preparing to listen to a client's breath sounds, what technique should a nurse use?

• A. Ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap.
• B. Listen to the right lung first, then the left lung, moving from top to bottom systematically.
• C. Ask the client to take deep breaths through the mouth.
• D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest.

Correct answer: D

Rationale: When preparing to listen to a client's breath sounds, a nurse should ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little more deeply than usual but to stop if feeling dizzy. The nurse should use the flat diaphragm end-piece of the stethoscope, holding it firmly on the chest wall. By using the diaphragm, the nurse can listen for at least one full respiration in each location, moving from side to side to compare sounds. This technique ensures a systematic and thorough assessment of lung sounds. Choice A is correct as it includes the proper positioning of the client and specifies the use of the diaphragm of the stethoscope. Choice B is incorrect as both lungs should be auscultated systematically, starting from the top and moving down. Choice C is incorrect as deep breaths, not shallow ones, are recommended for an accurate assessment of breath sounds.

2. When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?

• A. The nurse speaks loudly.
• B. The nurse allows additional time after each instruction to allow the client to process.
• C. The nurse provides supplemental written resources.
• D. The nurse breaks up the education into multiple shorter sessions.

Correct answer: A

Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.

3. When should rehabilitation services begin?

• A. when the client enters the health care system.
• B. after the client requests rehabilitation services
• C. after the client's physical condition stabilizes.
• D. when the client is discharged from the hospital.

Correct answer: A

Rationale: Rehabilitation services should begin when the client enters the health care system to ensure early intervention and optimal outcomes. Initiating rehabilitation early can help prevent complications, improve recovery, and enhance overall well-being. Option B is incorrect because waiting for the client to request services may lead to delays in starting treatment, potentially affecting the recovery process. Option C is incorrect as rehabilitation can often commence even when the client's physical condition is not fully stabilized, as early intervention is crucial for progress. Option D is incorrect as beginning rehabilitation only after hospital discharge may not be ideal, as early intervention within the healthcare system is preferred for a more effective recovery journey.

4. A nurse is reviewing the medical record of an older client with presbycusis. Which finding would the nurse expect to note in the client's record?

• A. Difficulty hearing whispered words in the voice test
• B. Improved hearing ability during conversational speech
• C. Unilateral conductive hearing loss
• D. Difficulty hearing low-pitched tones

Correct answer: A

Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and consonants during conversational speech. Choice A is correct because it reflects the expected finding in presbycusis. Choices B, C, and D are incorrect because presbycusis does not result in improved hearing ability during conversational speech, unilateral conductive hearing loss, or difficulty hearing low-pitched tones.

5. What is the primary force in sex education in a child's life?

• A. school nurse
• B. peers
• C. parents
• D. media

Correct answer: C

Rationale: Parents are the primary force in sex education in a child's life. Parents play a central role in shaping a child's understanding of sex from an early age. They provide continuous guidance, values, and information about sex and relationships. While the school nurse is involved in formal sex education and counseling within the school setting, parents have the most direct and significant impact on a child's sex education. Peers become more influential during adolescence, but their information may not always be accurate or appropriate. The media also exert significant influence on children's perceptions of sex through various forms of entertainment like movies, TV shows, and video games, but parents remain the primary educators on this subject.

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