Nursing Elites

1. A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?

• A. Asking the client to stick out his or her tongue and watching for tremors
• B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
• C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
• D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

Correct answer: D

Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.

2. A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse provides the mother with which information?

• A. To monitor the infant for infection and, if a fever develops, to contact the pediatrician
• B. That the stools should be solid and pale yellow to light brown
• C. That this is normal for breastfed infants
• D. To decrease the number of feedings by two per day

Correct answer: C

Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools, which is considered normal. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. It is essential for the mother to understand that seedy, mustard-yellow stools are expected in breastfed infants, indicating that there is no need for concern. Monitoring for infection as the first response without other symptoms can cause unnecessary anxiety. Decreasing the number of feedings without valid reasons can lead to inadequate nutrition for the newborn. Therefore, the correct advice for the nurse to provide in this scenario is that seedy, mustard-yellow stools are normal for breastfed infants, reassuring the mother and promoting proper understanding of newborn stool characteristics.

3. A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?

• A. Notifying the healthcare provider
• B. Stopping the oxytocin infusion
• C. Checking the woman's blood pressure and pulse
• D. Increasing the intravenous (IV) rate of the nonadditive solution

Correct answer: B

Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.

4. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:

• A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
• B. "Some studies show that ginseng enhances in vitro sperm motility."?
• C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
• D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?

Correct answer: B

Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.

5. Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?

• A. single, adult men
• B. single mothers with 2 or 3 children
• C. runaway adolescents
• D. single, adult women

Correct answer: B

Rationale: Single mothers with two or three children are indeed the fastest-growing segment of the homeless population. These families, where the majority of children are under the age of five, make up more than one-third of the homeless population in the United States. While single, adult men have traditionally been the largest group in the homeless population, single mothers with children have been increasing in numbers. Runaway adolescents, although a significant group of homeless children, do not represent the fastest-growing segment of the homeless population. Single, adult women are not specified as the fastest-growing segment.

Similar Questions