Nursing Elites

1. When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?

• A. 1+ edema
• B. 2+ edema
• C. 3+ edema
• D. 4+ edema

Correct answer: C

Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.

2. The LPN is taking care of a 176-pound client who has recently been diagnosed with diabetes. The primary healthcare provider has written an order for Lantus� (insulin glargine injection) 100 units/mL, using weight-based dosing of 0.2 units/kg per day. The LPN should prepare ____ units for administration.

• A. 12
• B. 35
• C. 16
• D. 9

Correct answer: B

Rationale: To calculate the correct dosage, first convert the client's weight from pounds to kilograms. As 1 kg = 2.2 pounds, 176 pounds � 2.2 = 80 kg. The client should receive 0.2 units for every kilogram, which equals 16 units. Therefore, the total amount to prepare is 16 units x 100 units/mL = 1600 units. Considering the medication concentration of 100 units/mL, 1600 units � 100 units/mL = 16 mL. However, since the question asks for the number of units, the final answer is 16 units x 2 injections = 32 units. Therefore, the LPN should prepare 32 units for administration.

3. A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?

• A. Ptosis
• B. Nystagmus
• C. Scleral icterus
• D. Exophthalmos

Correct answer: B

Rationale: When a nurse observes rapid, involuntary oscillating movements of the eyeball in a client, this is described as nystagmus. Nystagmus appears as a fine oscillating movement, most notable around the iris. It is important to assess for nystagmus when evaluating ocular muscle weakness. Mild nystagmus at extreme lateral gaze is considered normal; nystagmus in any other position is not. Ptosis refers to a drooping of the eyelid, not rapid eye movements. Scleral icterus is the yellowing of the sclera up to the cornea, indicating jaundice, not related to eye movements. Exophthalmos is a noticeable protrusion of the eyeball, typically seen in hyperthyroidism, not associated with rapid oscillating eye movements.

4. A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

• A. Testing for the strength of each muscle joint
• B. Percussing at the location of the median nerve
• C. Checking for repetitive movements in the joints
• D. Asking the client to flex the wrist 90 degrees while holding the hands back to back

Correct answer: B

Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.

5. A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?

• A. centration
• B. causality
• C. nonreversibility
• D. conservation

Correct answer: D

Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.

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