Nursing Elites

1. Which term best describes changes such as retirement, grandparenting, and increased dependence on others?

• A. Moral
• B. Psychosocial
• C. Self-esteem
• D. Psychomotor

Correct answer: B

Rationale: The correct answer is 'Psychosocial.' Retirement, grandparenting, and increased dependence on others are examples of psychosocial changes because they involve social interactions, relationships, and psychological aspects. 'Moral' (Choice A) does not directly relate to the changes mentioned. 'Self-esteem' (Choice C) is more about self-perception and confidence, not the social changes mentioned. 'Psychomotor' (Choice D) refers to physical movements and skills, which are not the focus of the changes described in the question.

2. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.

• A. Client has an actual health problem
• B. Client has a wellness diagnosis
• C. Collaborative health problem needs to be written
• D. Possible nursing diagnosis exists

Correct answer: B

Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.

3. Improper placement of the hands under the rib cage when performing the Heimlich maneuver could result in:

• A. damage to the manubrium of the sternum.
• B. damage to the xiphoid process.
• C. damage to the coccyx.
• D. None of the above is possible, even with improper hand placement.

Correct answer: B

Rationale: The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum. Placing the hands improperly during the Heimlich maneuver too close to this process can result in it breaking off and potentially causing damage to internal organs. Choices A and C are incorrect because the manubrium of the sternum and the coccyx are not in the area where the hands would typically be placed during the Heimlich maneuver.

4. A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?

• A. Wake the infant before beginning the examination.
• B. Examine the infant's hips before the infant wakes up.
• C. Auscultate the lungs and heart while the infant is still sleeping.
• D. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.

Correct answer: C

Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.

5. During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?

• A. Behavior
• B. Cognition
• C. Affect and mood
• D. Perceptual disturbances

Correct answer: B

Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.

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