Nursing Elites

1. As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?

• A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments.
• B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
• C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments.
• D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.

Correct answer: D

Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.

2. A patient diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Treatment most likely provided by the center includes

• A. Medical management of symptoms
• B. Daily psychotherapy
• C. Constant staff supervision
• D. Psychological stabilization

Correct answer: A

Rationale: Community mental health centers focus on rehabilitation, vocational needs, education, and socialization, as well as on the management of symptoms and medication. For a patient with a mild anxiety disorder, the primary focus would be on providing medical management of symptoms, such as prescribing appropriate medications and monitoring their effectiveness. Daily psychotherapy is not typically provided in community mental health centers for mild cases, as it may not be necessary. Constant staff supervision and psychological stabilization are more suited for patients requiring a higher level of care or in acute settings where continuous monitoring and stabilization are essential.

3. A nurse is assigned to care for a deaf client. During her lunch hour, she visits the hospital library and reads more about deaf culture in order to better provide appropriate care for her client. This action is an example of:

• A. Cultural knowledge
• B. Cultural noise
• C. Cultural diversity
• D. Cultural divide

Correct answer: A

Rationale: Cultural knowledge involves seeking information and educating oneself about different cultural groups. In this scenario, the nurse is demonstrating cultural knowledge by learning more about deaf culture to improve the care provided to the deaf client. This proactive approach helps in understanding the client's background, beliefs, and communication preferences, leading to better outcomes. 'Cultural noise' and 'Cultural divide' are incorrect as they do not reflect the nurse's positive action of seeking knowledge to enhance care. 'Cultural diversity' is also incorrect as it does not accurately describe the nurse's specific action of acquiring knowledge about a particular culture.

4. A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

• A. Family history of heart disease
• B. Overweight
• C. Smoking
• D. Age

Correct answer: A

Rationale: A family history of heart disease is an inherited risk factor for developing atherosclerosis. This factor is not modifiable through lifestyle changes. Studies have shown that having a first-degree relative with heart disease significantly increases the individual's risk of developing atherosclerosis. Overweight, smoking, and age are not hereditary risk factors for atherosclerosis. Overweight and smoking are lifestyle-related risk factors, while age is a non-modifiable risk factor that increases with time but is not directly inherited.

5. A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?

• A. Palpating the temperature of both feet
• B. Evaluating pulses bilaterally
• C. Turning the client to a side-lying position
• D. Relieving heel pressure by placing a pillow under the foot

Correct answer: C

Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.

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