Nursing Elites

1. A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?

• A. Pulling the pinna up and back
• B. Pulling the pinna down and forward
• C. Tipping the client's head down and toward the examiner
• D. Tipping the client's head down and away from the examiner

Correct answer: A

Rationale: In an adult client, the healthcare professional should pull the pinna up and back before inserting the otoscope. This action helps straighten the S shape of the ear canal, making it easier to insert the otoscope directly and comfortably. Tipping the client's head down and toward or away from the examiner is not the correct action when using an otoscope in an adult. Pulling the pinna down and forward is typically done when examining an infant or a child younger than 3 years old to straighten their ear canal for better visualization.

2. A nurse assisting with data collection notes that the client's skin is very dry. The nurse documents this finding using which term?

• A. Xerosis
• B. Pruritus
• C. Seborrhea
• D. Actinic keratoses

Correct answer: A

Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Xerosis is the correct term for very dry skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin, but it does not specifically refer to dry skin. Seborrhea is a skin condition characterized by overproduction of sebum, leading to excessive oiliness or dry scales, not necessarily indicating very dry skin. Actinic keratoses are sun-related skin lesions that are premalignant and not associated with dry skin.

3. The goals of palliative care include all of the following except:

• A. giving clients with life-threatening illnesses the best quality of life possible
• B. taking care of the whole person"?body, mind, spirit, heart, and soul
• C. no interventions are needed because the client is near death
• D. supporting the needs of the family and client

Correct answer: C

Rationale: The goals of palliative care include choices A, B, and D. Choice C, 'no interventions are needed because the client is near death,' is not part of palliative care. Palliative care involves giving clients with life-threatening illnesses the best quality of life possible, taking care of the whole person"?body, mind, spirit, heart, and soul, and supporting the needs of the family and client. Interventions are crucial in palliative care to ensure the comfort and well-being of the client until the end of life. Therefore, the correct answer is that no interventions are needed because the client is near death.

4. While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?

• A. Liver enlargement
• B. Ovarian infection
• C. Spleen enlargement
• D. Kidney inflammation

Correct answer: D

Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.

5. A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:

• A. increased ferning capacity.
• B. lack of ferning.
• C. spinnbarkheit.
• D. inhospitable.

Correct answer: C

Rationale: The nurse should document the finding as 'spinnbarkheit.' Spinnbarkheit is the term used to describe the clear, thin, and elastic cervical mucus that can be stretched 8-10 cm, indicating ovulation. It helps couples determine the most fertile period for conception. Ferning capacity or crystallization increases as ovulation approaches, but it requires microscopic examination to be confirmed. Lack of ferning cannot be determined without such examination. 'Inhospitable' cervical mucus refers to patterns that prohibit sperm motility, caused by various factors like hormone levels or infection. These conditions cannot be assessed based solely on the description provided in the question.

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