Nursing Elites

1. A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: B

Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.

2. During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?

• A. Cranial nerve X
• B. Cranial nerve V
• C. Cranial nerve IX
• D. Cranial nerve XII

Correct answer: D

Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.

3. The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness?

• A. The child no longer has temper tantrums.
• B. The child can remove his or her own clothing.
• C. The child has been walking for 2 years.
• D. The child can eat using a fork and knife.

Correct answer: B

Rationale: Signs of physical readiness for toilet training include the child's ability to remove his or her own clothing. This ability indicates the child has developed the necessary fine motor skills to manage clothing during toilet training. The other choices are incorrect because temper tantrums, walking for a specific period, and using utensils are not indicators of physical readiness for toilet training.

4. Following the change of shift report, when can or should the nurse's plan be altered or modified during the shift?

• A. halfway through the shift
• B. at the end of the shift before the nurse reports off
• C. when needs change
• D. after the top-priority tasks have been completed

Correct answer: C

Rationale: The correct answer is 'when needs change.' It is crucial for the nurse to remain adaptable and adjust the plan promptly when the patient's needs or condition change. Choice A, 'halfway through the shift,' may not align with the timing of when needs actually change, making it less optimal for plan modifications. Choice B, 'at the end of the shift before the nurse reports off,' is too late to address evolving needs effectively. Choice D, 'after the top-priority tasks have been completed,' limits the nurse's ability to respond promptly to changing priorities, as needs may shift before all top-priority tasks are finished.

5. A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?

• A. vitiligo
• B. erythema
• C. cyanosis
• D. chloasma

Correct answer: D

Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes during pregnancy. Vitiligo is characterized by depigmented patches, erythema is redness of the skin due to increased blood flow, and cyanosis is a bluish discoloration due to poor circulation or lack of oxygen, none of which are typical skin-color variations during pregnancy. Therefore, in a pregnant client, the most likely normal skin-color variation to be displayed is chloasma.

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