Nursing Elites

1. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

• A. The client should remove all scatter rugs from the floor and minimize clutter.
• B. The client should not limit her movement within the home unless advised by the physician.
• C. The client should have a raised toilet seat and grab bars available in the bathroom.
• D. The client should not wear a robe and socks while walking in the house.

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

2. A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?

• A. The client appears anxious.
• B. Blood pressure is 170/80 mm Hg.
• C. The client states that he has a rash.
• D. The client has diminished reflexes in the legs.

Correct answer: C

Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says. Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.

3. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?

• A. Coffee
• B. A tuning fork
• C. A wisp of cotton
• D. An ophthalmoscope

Correct answer: C

Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.

4. While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

• A. Optic
• B. Abducens
• C. Olfactory
• D. Hypoglossal

Correct answer: C

Rationale: The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.

5. Quality is defined as a combination of all of the following except:

• A. conforming to standards.
• B. performing at the minimally acceptable level.
• C. meeting or exceeding customer requirements.
• D. exceeding customer expectations.

Correct answer: B

Rationale: The correct answer is 'performing at the minimally acceptable level.' Quality is about meeting or exceeding customer requirements and expectations, as well as conforming to standards. The term 'performing at the minimally acceptable level' implies just meeting the minimum requirements, which falls short of the comprehensive definition of quality in terms of customer satisfaction and excellence. Therefore, this choice is the exception when defining quality. Choices A, C, and D align with the definition of quality as they all involve meeting or surpassing certain criteria for customer satisfaction and product excellence, which are essential components of quality management.

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