Nursing Elites

1. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?

• A. Ask the patient how he or she is feeling.
• B. Document the findings in the patient's record.
• C. Wait 10 minutes and auscultate the sound again.
• D. Ask another nurse to double-check the finding.

Correct answer: D

Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.

2. A patient is asked to abduct her arms. Which of the following accurately describes her arm movement?

• A. She moves her arms away from her trunk
• B. She moves her arms toward her trunk
• C. She rotates her arms at the wrists while holding them away from her body
• D. She crosses her arms over her abdomen

Correct answer: A

Rationale: Abduction refers to moving a body part away from the midline of the body. In this case, when the patient abducts her arms, she is moving them away from her trunk. Choice A is correct. Choices B, C, and D are incorrect. Choice B describes adduction, which is the movement of a body part toward the midline. Choice C describes wrist rotation, not arm abduction. Choice D describes crossing the arms over the abdomen, which is not the movement associated with abduction.

3. What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?

• A. The popliteal artery should be auscultated to obtain thigh pressure.
• B. The best position to measure thigh pressure is the prone position.
• C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
• D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.

Correct answer: C

Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.

4. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?

• A. Belief in and worship of God or gods
• B. Being closely tied to one's ethnic background
• C. Attendance at a specific church or place of worship
• D. A connection with something larger than oneself and belief in transcendence

Correct answer: D

Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.

5. Intermittent fevers are:

• A. fevers which come and go.
• B. fevers which rise and fall but are always considered above the patient's average temperature.
• C. fevers which fluctuate more than three degrees and never return to normal.
• D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

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