Nursing Elites

1. How should a nurse listen to the breath sounds of a client?

• A. Ask the client to lie prone.
• B. Ask the client to breathe in and out through the nose.
• C. Hold the bell of the stethoscope lightly against the chest.
• D. Listen for at least one full respiration in each location on the chest.

Correct answer: D

Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.

2. When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?

• A. polyandry
• B. sororal
• C. nonsororal
• D. soronal

Correct answer: D

Rationale: The correct answer is 'soronal.' The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as sororal. Polyandry refers to multiple husbands, which is rare. Nonsororal polygamy is when the wives are not sisters. Sororate polygamy specifies that a husband must marry his wife’s sister if she dies. Therefore, in this scenario, the family structure described by the client fits the definition of soronal polygamy.

3. A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?

• A. If your 2-year-old becomes angry or jealous, you should consider preparing the child for the new sibling rather than seeking psychological intervention.
• B. Don't worry; every 2-year-old may need time to adjust to a newborn sibling.
• C. Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.
• D. A 2-year-old toddler focuses on exploring the environment, but it's important to prepare the child for the new sibling.

Correct answer: C

Rationale: The correct response by the nurse is, 'Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.' Toddlers are generally unaware of the changes during pregnancy and may not understand the impending arrival of a new sibling. It is essential to prepare the child gradually for the new baby's arrival by making any necessary changes in sleeping arrangements beforehand. Expecting a young child to immediately welcome a new sibling without prior preparation is unrealistic. Option A is incorrect as suggesting psychological intervention prematurely is not appropriate. Option B is incorrect as assuming all 2-year-olds would immediately welcome a newborn is unrealistic. Option D is incorrect as dismissing the concerns without addressing the need for preparation is not appropriate in this situation.

4. During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?

• A. the potential hazards of accidents
• B. appropriate nutrition now that the child has been weaned from breastfeeding
• C. toilet training
• D. how to prevent accidents in the house

Correct answer: A

Rationale: During a routine health screening for a 1-year-old child, discussing the potential hazards of accidents is crucial. Accidents are the primary source of injury in children and can be life-threatening. Addressing appropriate nutrition now that the child has been weaned from breastfeeding should have already been discussed. Toilet training is important but is typically addressed at a later age as one year is too early for this milestone. While preventing accidents in the house is important, focusing on the potential hazards of accidents in general is more comprehensive and critical for the child's safety.

5. A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?

• A. Uses a cotton-tipped swab to carefully clean inside the infant's nose
• B. Uncovers only the body part being washed
• C. Washes the diaper area first
• D. Washes the infant's chest first

Correct answer: B

Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.

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