Nursing Elites

1. While assessing a client’s skin, the nurse notes the presence of several large red-blue and purple areas on the client’s body that do not blanch when pressure is applied. The nurse documents this finding using which term?

• A. Psoriasis
• B. Anasarca
• C. Petechiae
• D. Ecchymosis

Correct answer: D

Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues, commonly known as a bruise. The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is characterized by scaly erythematous patches with silvery scales on top, usually found on specific areas like the scalp, elbows, knees, low back, and anogenital area. Anasarca is bilateral or generalized edema, indicating a central problem like congestive heart failure or kidney failure. Petechiae are tiny purple or red spots resulting from tiny hemorrhages within the dermal and subdermal areas. Therefore, in this case, the correct term to document the described finding is Ecchymosis.

2. While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?

• A. Liver enlargement
• B. Ovarian infection
• C. Spleen enlargement
• D. Kidney inflammation

Correct answer: D

Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.

3. The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?

• A. "I will need to avoid eating excessive leafy greens."?
• B. "It's best to take this medication with food."?
• C. "I can't wait to get back to my nightly glass of wine."?
• D. "I should try to take this medication at the same time every day."?

Correct answer: C

Rationale: The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.

4. An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?

• A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours.
• B. Ask the registered nurse to obtain a prescription for a nighttime sedative.
• C. Report the findings to the registered nurse.
• D. Document the findings in the medical record.

Correct answer: D

Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Since the reported data are normal age-related changes, the appropriate action for the nurse would be to document the findings in the medical record. Reporting the findings to the registered nurse is unnecessary as these changes are expected with aging and do not indicate a need for immediate intervention. Prescribing sedatives should be avoided as a first-line approach due to potential side effects and risks, especially in older adults. Encouraging the consumption of stimulants like caffeinated beverages during the daytime may further disrupt sleep patterns, which is counterproductive in addressing the client's reported sleep issues.

5. A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?

• A. 16 weeks
• B. 6 weeks
• C. 8 weeks
• D. 12 weeks

Correct answer: A

Rationale: Fetal movements (quickening) are first noticed by multigravida pregnant women at 16 to 20 weeks of gestation and gradually increase in frequency and strength. This is when the mother typically begins to feel the baby's movements. Choices B, C, and D are incorrect because fetal movements are not felt as early as 6, 8, or 12 weeks of gestation. At 6 weeks, the embryo's movements are not yet strong enough to be felt by the mother. By 8 weeks, the movements are still too subtle to be perceived. At 12 weeks, although fetal movements start, they are usually not strong enough to be felt by the mother.

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