Nursing Elites

1. A patient reports, "I tore 3 of my 4 Rotator cuff muscles in the past."? Which of the following muscles cannot be considered as possibly being torn?

• A. Teres minor
• B. Teres major
• C. Supraspinatus
• D. Infraspinatus

Correct answer: B

Rationale: The correct answer is Teres major. The Rotator Cuff consists of Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis muscles, not Teres major. Teres major is not part of the rotator cuff, so it cannot be considered as possibly being torn. The other choices, Teres minor, Supraspinatus, and Infraspinatus, are all part of the Rotator Cuff and could potentially be torn in this patient's case.

2. Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

• A. refusal to walk
• B. not pulling to a standing position
• C. negative Trendelenburg sign
• D. negative Ortolani sign

Correct answer: B

Rationale: The correct answer is 'not pulling to a standing position.' An 11-12-month-old child not pulling to a standing position may be at risk for developmental dysplasia of the hip. By this age, children typically pull to a standing position, and failure to do so should raise concerns. Refusal to walk is a broader observation and not specific to hip dysplasia. The Trendelenburg sign indicates weakness of the gluteus medius muscle, not hip dysplasia. The Ortolani sign is used to detect congenital subluxation or dislocation of the hip, which is different from developmental dysplasia of the hip.

3. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?

• A. The young adult is sensitive to criticism.
• B. The young adult verbalizes unrealistic fears.
• C. The young adult verbalizes disappointment with life.
• D. The young adult verbalizes satisfaction with friendships.

Correct answer: D

Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.

4. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

• A. immobility
• B. altered growth and development
• C. hemarthrosis
• D. altered family processes

Correct answer: D

Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.

5. A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?

• A. Normally heard in the lungs
• B. Hollow sounds heard over the trachea and larynx
• C. Rustling sounds heard over the peripheral lung fields
• D. Abnormal sounds that should not be heard in the lungs

Correct answer: D

Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.

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