Nursing Elites

1. An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?

• A. The client has a low cardiac output.
• B. The client has a high cardiac output.
• C. The client has a normal cardiac output.
• D. The client will need a blood transfusion.

Correct answer: C

Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.

2. A nurse is trying to motivate a client toward more effective management of a therapeutic regimen. Which of the following actions by the nurse is most likely to be effective in increasing the client's motivation?

• A. determining if the client has any family or friends living nearby
• B. developing a concise discharge plan and reviewing it with the client
• C. teaching the client about the disorder at the client's level of understanding
• D. making a referral to an area agency for client follow-up

Correct answer: C

Rationale: To effectively motivate the client, it is important to educate them about the disorder at their level of understanding. This helps the client comprehend the importance of the therapeutic regimen and empowers them to actively participate in their treatment. Choice A, determining if the client has any family or friends living nearby, may provide social support but is less likely to directly impact the client's motivation compared to educating them about their condition. Developing a concise discharge plan, as in choice B, is crucial for continuity of care but may not directly enhance the client's motivation as effectively as providing education tailored to their level of understanding. Making a referral for follow-up, as in choice D, is important for ongoing care but may not have the same immediate impact on the client's motivation as educating them about their condition.

3. The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?

• A. "I am nervous about how painful labor will be."?
• B. "I need to review my finances and make sure I am prepared to care for a child."?
• C. "I hate this nausea that I've been having for a week."?
• D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?

Correct answer: D

Rationale: The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.

4. When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:

• A. "Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse."?
• B. "Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse."?
• C. "The average time it takes someone your age to conceive is 5.3 months, so if you haven't conceived by then, we can refer you."?
• D. "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year."?

Correct answer: D

Rationale: The best response in this scenario is to offer immediate guidance while also indicating when fertility counseling should be sought. While Choice A is technically correct as guidelines recommend seeking fertility counseling after 1 year of unprotected intercourse, it lacks providing immediate guidance. Choice B suggests seeking counseling after 6-9 months, which is earlier than the standard recommendation of 1 year. Choice C mentions the average time to conceive for someone of the client's age without addressing the client's current concern. Therefore, Choice D is the most appropriate response as it offers immediate guidance along with a plan for referral if needed.

5. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

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