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 nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

• A. Loss of hearing acuity
• B. A problem with balance
• C. A problem with distant hearing
• D. A problem discriminating high-pitched and low-pitched sounds

Correct answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

3. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

• A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
• B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
• C. The organ procurement organization makes the decision regarding which organs to harvest.
• D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.

Correct answer: A

Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.

4. A home health care nurse is visiting a male African American client who was recently discharged from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications?

• A. The client's grandson
• B. The client's mother
• C. The client's father
• D. The client's son

Correct answer: B

Rationale: In the African American family structure, the woman, especially the mother, often plays a central role in healthcare decisions and maintaining family health. It is essential for the nurse to involve the client's mother in teaching him about his prescribed medications as she may be responsible for his care and treatment decisions. While other family members may also be involved, the African American family is often matrifocal, emphasizing the importance of the mother's role. Therefore, it is crucial for the nurse to ensure the client's mother is present during medication teaching. Choices A, C, and D are incorrect as they do not align with the traditional African American family structure and the role of women in healthcare decisions.

5. A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?

• A. Collect health history information first while initiating emergency measures.
• B. Ask health history questions while performing the examination and initiating emergency measures.
• C. Collect all information requested on the history form, including social support, strengths, and coping patterns.
• D. Perform emergency measures and delay health history questions until after treating the fractures in the operating room.

Correct answer: B

Rationale: When a client is alert and cooperative but has sustained multiple fractures, the nurse should prioritize obtaining health history information while performing the examination and initiating emergency measures. This approach allows the nurse to gather essential information without delaying immediate interventions. Option A is incorrect because collecting health history information before addressing the immediate need for treatment may lead to a delay in necessary interventions. Option C is incorrect as it includes non-urgent aspects of data collection that are not a priority in this critical situation. Option D is incorrect because delaying health history questions until after treating the fractures may result in missing crucial information essential for the client's immediate care.

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