Nursing Elites

1. The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?

• A. Weight gain
• B. Heat intolerance
• C. Increased appetite
• D. Frequent diarrhea

Correct answer: A

Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.

2. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Mitral stenosis
• C. Aortic regurgitation
• D. Tricuspid stenosis

Correct answer: B

Rationale: The correct answer is B: Mitral stenosis. A high-pitched scratching sound heard during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border indicates mitral stenosis, not a pericardial friction rub. Pericardial friction rub is a to-and-fro, grating, or scratching sound due to inflamed pericardial surfaces rubbing together, typically heard in early diastole and late systole. Aortic regurgitation and tricuspid stenosis would present with different auscultatory findings compared to the described scenario, making them incorrect choices in this context.

3. A client has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

• A. This type of hearing aid allows for fine-tuning of volume.
• B. I should ensure the hearing aid stays secure during exercise.
• C. I might hear a whistling sound when I first insert the hearing aid.
• D. I will be sure to remove my hearing aid before taking a shower.

Correct answer: D

Rationale: The correct answer is D because removing the hearing aid before taking a shower is essential to prevent water damage, as moisture can harm the device. Choice A is incorrect because behind-the-ear hearing aids do allow for fine-tuning of volume. Choice B is incorrect because exercise may cause the hearing aid to shift position, so it's important to ensure it stays secure. Choice C is incorrect because hearing a whistling sound when inserting the hearing aid may indicate improper placement or fit.

4. When providing mouth care for an unconscious client, what action should the nurse take?

• A. Turn the client’s head to the side.
• B. Place two fingers in the client’s mouth to open it.
• C. Brush the client’s teeth once per day.
• D. Inject mouth rinse into the center of the client’s mouth.

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

5. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

• A. “I believe in this case you should make an exception and accept the blood transfusion.”
• B. “I know your family would approve of your decision to have a blood transfusion.”
• C. “Why does your religion mandate that you cannot receive any blood transfusions?”
• D. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”

Correct answer: D

Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.

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