Nursing Elites

1. An adult patient is at the clinic for a physical examination. The patient states that they are feeling 'very anxious' about the physical examination. What steps can the nurse take to make the patient more comfortable?

• A. Appear unhurried and confident when examining the patient.
• B. Leave the room when the patient undresses unless they need assistance.
• C. Ask the patient to change into an examining gown and to leave their undergarments on.
• D. Measure vital signs at the beginning of the examination to gradually accustom the patient.

Correct answer: A: Appear unhurried and confident when examining the patient.

Rationale: To help alleviate the patient's anxiety, the nurse should appear unhurried and confident during the examination. This can make the patient feel more at ease and reassured. It is important for the nurse to respect the patient's privacy by leaving the room while the patient changes unless assistance is needed. The patient should be instructed to change into an examining gown while leaving their undergarments on, providing a sense of comfort and familiarity. Additionally, measuring vital signs at the beginning of the examination can help gradually acclimate the patient to the process, making it less overwhelming. Therefore, the correct answer is to appear unhurried and confident when examining the patient. Choices B, C, and D are incorrect because they do not directly address the patient's anxiety or provide comfort in the same way as the correct answer.

2. Which desired outcome written by the nurse is correctly written and measurable?

• A. Client will have a normal bowel pattern by April 2
• B. The client will lose 4 lbs. within the next 2 weeks
• C. The nurse will provide skin care at least 3 times each day
• D. The client will breathe better after resting for 10 minutes

Correct answer: The client will lose 4 lbs. within the next 2 weeks

Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.

3. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

• A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
• B. Obtain a thorough history and physical assessment from the patient’s family member.
• C. Immediately perform a complete history and physical assessment to obtain baseline information.
• D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.

Correct answer: Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.

Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.

4. When measuring a patient’s body temperature, what factor should be considered that can influence the temperature?

• A. Constipation
• B. Diurnal cycle
• C. Nocturnal cycle
• D. Patient’s emotional state

Correct answer: Diurnal cycle

Rationale: When measuring body temperature, it is essential to consider factors that can influence it. The diurnal cycle, which refers to the body's natural temperature variations throughout a 24-hour period, can impact body temperature readings. Factors like exercise, age, and environment can also affect body temperature. Constipation does not directly influence body temperature. The 'nocturnal cycle' is not a recognized term in relation to body temperature. While a patient's emotional state can affect vital signs, it is not a primary factor in influencing body temperature measurements.

5. A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?

• A. A history of hepatitis C five years previously
• B. Cholecystitis requiring cholecystectomy one year previously
• C. Asymptomatic diverticulosis
• D. Crohn’s disease in remission

Correct answer: A history of hepatitis C five years previously

Rationale: A history of hepatitis C five years previously would prevent a donor from donating blood for transfusion. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis requiring cholecystectomy one year previously, asymptomatic diverticulosis, and Crohn’s disease in remission are not contraindications for blood donation as they do not pose a risk of transmitting infections to the recipient.

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