Nursing Elites

1. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?

• A. The patient should be evaluated for kidney disease
• B. The specimen was probably left at room temperature for more than two hours
• C. The specimen is positive for bacteria
• D. The specimen should be stored in an area protected from light

Correct answer: D

Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.

2. A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak "perfect English."? What is this woman likely experiencing?

• A. Culture shock
• B. Cultural taboos
• C. Cultural unfamiliarity
• D. Culture disorientation

Correct answer: A

Rationale: The woman in the scenario is likely experiencing culture shock. Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group due to sudden strangeness, unfamiliarity, and incompatibility with the individual's perceptions and expectations. In this case, the woman's feelings of shyness and retreating due to not feeling confident in speaking 'perfect English' align with symptoms of culture shock. The other choices are incorrect: Cultural taboos refer to behaviors or actions that are prohibited within a particular culture; cultural unfamiliarity suggests a lack of knowledge about a specific culture, which is not the case here; and culture disorientation is not a commonly used term in cultural psychology, making it an incorrect option.

3. When planning a cultural assessment, what component should the nurse include?

• A. Family history
• B. Chief complaint
• C. Medical history
• D. Health practices

Correct answer: D

Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.

4. The Rule of Nines is used to:

• A. determine the amount of the body surface that has been burned
• B. assess the level of oxygen saturation in a body that has been burned.
• C. determine the level of tissue damage that has occurred in a burn.
• D. None of the above.

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

5. The healthcare professional is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?

• A. Measuring the infant's length using a tape measure
• B. Weighing the infant on an electronic standing scale
• C. Measuring the chest circumference at the nipple line with a tape measure
• D. Measuring the head circumference by wrapping the tape measure around the head

Correct answer: C

Rationale: For accurate measurements, specific techniques are required for different parameters in infants. Measuring the chest circumference involves encircling the chest at the nipple line. Length should be measured on a horizontal measuring board. Weight should be measured using a platform-type balance scale. Head circumference measurement entails ensuring the tape is aligned at the eyebrows and prominent frontal and occipital bones for the widest span. Therefore, the correct technique for measuring the chest circumference is at the nipple line with a tape measure. The other options are incorrect because length should be measured on a horizontal board, weight should be measured on a balance scale, and head circumference should be measured around the head, not over the nose and cheekbones.

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