Nursing Elites

1. A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s pulse?

• A. 4+
• B. 3+
• C. 2+
• D. 1+

Correct answer: C

Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client’s pulse as 2+ based on the description of a normal pulse. Therefore, the correct notation for the force of the client’s pulse is '2+' as it indicates a normal pulse. Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.

2. The greatest time savers when planning client care include all of the following except:

• A. reacting to the crisis of the moment
• B. setting goals
• C. planning
• D. specifying priorities

Correct answer: A

Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, specifying priorities, planning tasks, delegating where appropriate, reassessment, and ongoing evaluation of needs. Reacting to the crisis of the moment is not a time-saving strategy in client care planning; it can lead to inefficiency, lack of focus, and potentially missing important priority items. Therefore, the correct answer is 'reacting to the crisis of the moment.' Choices B, C, and D are essential components for effective client care planning as they help in organizing and prioritizing tasks, setting objectives, and ensuring a structured approach to care delivery.

3. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:

• A. terminating the pregnancy.
• B. preparing for the birth of a child with special needs.
• C. accessing support services before the birth.
• D. completing the grieving process before the birth.

Correct answer: D

Rationale: Diagnostic genetic counseling provides clients with important information to make informed decisions regarding their pregnancy. Clients can choose to terminate the pregnancy, prepare for the birth of a child with special needs, and access support services before the birth based on the genetic testing results. However, completing the grieving process before the birth is not a typical choice during genetic counseling. The grieving process, if needed, may extend beyond the prenatal period, especially if the findings are concerning or indicate potential issues. Therefore, completing the grieving process before the birth is the exception among the provided options.

4. A healthcare provider is assisting with data collection on a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the healthcare provider obtain data on from the client?

• A. Age
• B. Ethnicity
• C. Hypertension
• D. Genetic inheritance

Correct answer: C

Rationale: The correct answer is 'Hypertension.' Risk factors for CAD are categorized as modifiable and unmodifiable. Unmodifiable risk factors include age, sex, ethnicity, genetic predisposition, and family history of heart disease. Modifiable risk factors include increased concentrations of serum lipids, hypertension, cigarette smoking, obesity, and level of physical activity. In this case, hypertension is a modifiable risk factor that the healthcare provider would obtain data on. Choices A, B, and D are incorrect because age, ethnicity, and genetic inheritance are unmodifiable risk factors for CAD, not modifiable ones.

5. When performing the confrontation test to assess peripheral vision, what action should the nurse take?

• A. Asks the client to identify a small object brought into the visual field
• B. Has the client cover one eye while the nurse covers one eye and slowly advances a target midline between them
• C. Covers one eye, while the client covers the opposite eye, and brings a small object into the visual field
• D. Positions at eye level with the client, covers one eye, and has the client cover the opposite eye, then brings a small object into the visual field

Correct answer: D

Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits. Choices A, B, and C are incorrect. Choice A pertains to testing color vision, which is not part of the confrontation test. Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test. Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.

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