Nursing Elites

1. Which body plane divides the body into right and left sides?

• A. Frontal Plane
• B. Medial Plane
• C. Median Plane
• D. Transverse Plane

Correct answer: C

Rationale: The correct answer is the Median Plane, also known as the sagittal plane. It divides the body into right and left sides. The Frontal Plane, or coronal plane, divides the body into front and back sections. The Transverse Plane divides the body into superior (upper) and inferior (lower) sections. Therefore, choices A, B, and D are incorrect as they do not specifically divide the body into right and left sides.

2. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?

• A. Perform nursing activities throughout the entire shift
• B. Assess for signs of increased muscle tone
• C. Minimize environmental noise
• D. Teach clients to perform the Valsalva maneuver

Correct answer: C

Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.

3. During the general survey, what action is a component of the assessment?

• A. Observing the patient's body stature and nutritional status
• B. Interpreting the subjective information reported by the patient
• C. Measuring the patient's temperature, pulse, respirations, and blood pressure
• D. Observing specific body systems during the physical assessment

Correct answer: A

Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.

4. To properly read a meniscus,

• A. hold the measuring device at eye level and read the bottom of the curve of the liquid level
• B. hold the measuring device at eye level and read the top of the curve of the liquid level where the liquid adheres to the walls of the container.
• C. hold the measuring device at table level and, looking down into the measuring device, read the bottom of the curve of the liquid level.
• D. hold the measuring device at table level and, looking down into the measuring device, read the top of the curve of the liquid level.

Correct answer: A

Rationale: To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface. Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements. Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.

5. A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?

• A. Refer the infant to a physician for further evaluation.
• B. Consider these findings normal for a 1-month-old infant.
• C. Expect the chest circumference to be greater than the head circumference.
• D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.

Correct answer: B

Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.

Similar Questions