Nursing Elites

1. What is the best description of resonance?

• A. Sounds created by air-filled structures
• B. Short, high-pitched, and thudding
• C. Moderately loud with a musical quality
• D. Drum-like

Correct answer: A

Rationale: Resonance refers to the quality of sound produced by vibrations that are reinforced by other vibrations of the same frequency. In the context of the human body, resonance is often associated with sounds produced by air-filled structures like the lungs, vocal cords, and resonating cavities. Therefore, the best description of resonance from the given options is 'Sounds created by air-filled structures.' This choice aligns with the concept of resonance as it relates to sound production in the human body. Choices B, C, and D are incorrect as they do not specifically relate to the concept of resonance or its association with air-filled structures.

2. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

• A. Ineffective airway clearance related to thick, tenacious secretions.
• B. Ineffective airway clearance related to dry, hacking cough.
• C. Ineffective individual coping with COPD.
• D. Pain related to immobilization of affected leg.

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

3. How can preserving skin integrity impact the circular chain of infection?

• A. Host
• B. Reservoir
• C. Mode of transmission
• D. Portal of entry

Correct answer: D

Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.

4. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place the client's left arm on a pillow while he is sitting.
• B. Provide total care in assisting with the client's ADLs.
• C. Encourage mobility and avoid bed rest.
• D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.

Correct answer: A

Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.

5. During physical therapy, a client with Parkinson's disease makes the following statements. Which statement indicates the need for a referral to physical therapy?

• A. ''I have been experiencing more tremors in my left arm than before''
• B. ''I noticed that I am having a harder time holding on to my toothbrush''
• C. ''Lately, I feel like my feet are freezing up, as they are stuck to the ground''
• D. ''Sometimes, I feel I am making a chewing motion when I'm not eating''

Correct answer: C

Rationale: Feeling like the feet are freezing up and sticking to the ground is a common symptom of Parkinson's disease known as 'freezing of gait.' This symptom significantly impacts mobility and can be dangerous, indicating the need for specialized physical therapy interventions to address gait disturbances and improve mobility.

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