Nursing Elites

1. What is the initial technique used when examining a client's abdomen?

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

Correct answer: D

Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion. Palpation, auscultation, and percussion are secondary techniques used after visual inspection to further assess the abdomen for specific findings. Palpation involves feeling the abdomen for masses or tenderness, auscultation is listening for bowel sounds, and percussion is tapping the abdomen to assess for areas of dullness or resonance.

2. Which of the following parameters should be checked when assessing respirations?

• A. Rate
• B. Rhythm
• C. Symmetry
• D. All of the above

Correct answer: D

Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.

3. Examples of patients suffering from impaired awareness include all of the following except:

• A. A semiconscious or overfatigued patient
• B. A disoriented or confused patient
• C. A patient who cannot care for themselves at home
• D. A patient demonstrating symptoms of drug or alcohol withdrawal

Correct answer: C

Rationale: Patients with impaired awareness may exhibit symptoms such as being semiconscious, overfatigued, disoriented, confused, or demonstrating symptoms of drug or alcohol withdrawal. A patient who cannot care for themselves at home does not necessarily indicate impaired awareness, as this could be due to physical limitations or lack of support, rather than a cognitive deficit.

4. Which pulse's absence may not be a significant finding when a patient is admitted to the hospital?

• A. Apical
• B. Radial
• C. Pedal
• D. Femoral

Correct answer: C

Rationale: The absence of the pedal pulse may not be significant if the patient has poor peripheral circulation or if the healthcare provider is focused on other pulse points. The pedal pulse is often weaker and may not always be palpable due to various factors, making its absence less concerning in certain situations. However, the absence of other pulses like radial or femoral pulses may indicate more critical conditions and require immediate attention.

5. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

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