Nursing Elites

1. Nurse DMLM is correct in identifying the correct sequence of events during abdominal assessment if she identifies which of the following?

• A. Inspection, Auscultation, Percussion, Palpation
• B. Inspection, Percussion, Palpation, Auscultation
• C. Inspection, Palpation, Percussion, Auscultation
• D. Inspection, Auscultation, Palpation, Percussion

Correct answer: D

Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation, Percussion, Palpation. Start with Inspection to observe any visible abnormalities, followed by Auscultation to listen for bowel sounds, then Percussion to assess the density of underlying structures, and finally Palpation to feel for any tenderness or masses. Choices A, B, and C have the incorrect sequence of assessment techniques.

2. What nursing diagnosis would be most appropriate for a patient with heart failure?

• A. risk for infection
• B. fluid volume excess
• C. impaired body temperature
• D. ineffective airway clearance

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

3. What type of diet would most likely benefit a patient with cystic fibrosis?

• A. Low sodium
• B. Low fat
• C. Clear liquid
• D. High calorie, high protein

Correct answer: D

Rationale: Patients with cystic fibrosis often have malabsorption issues, leading to increased energy needs. A high-calorie, high-protein diet is recommended to help meet these needs, support growth, and maintain overall health. Choices A, B, and C do not address the specific dietary requirements associated with cystic fibrosis, making them less beneficial for these patients.

4. During times of staff and financial shortage, which method is the best and most effective?

• A. Functional Method
• B. Primary Nursing
• C. Team Nursing
• D. Modular Method

Correct answer: D

Rationale: During times of staff and financial shortage, the Modular Method is considered the best and most effective. This method allows for flexibility and adaptability in assigning tasks and responsibilities, making it easier to cope with limited resources. Functional Method (Choice A) focuses on the division of labor based on each staff member's skills, which may not be the most efficient during shortages. Primary Nursing (Choice B) and Team Nursing (Choice C) may require a more significant number of staff, making them less suitable during shortages.

5. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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