Nursing Elites

1. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

• A. Our child had chickenpox 6 months ago.
• B. Strep throat went through all the children at the day care last month.
• C. Both ears were infected over 3 months ago.
• D. Last week both feet had a fungal skin infection.

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

2. A healthcare provider is caring for a client who has a heart murmur. The healthcare provider is preparing to auscultate the pulmonary valve. Over which of the following locations should the healthcare provider place the bell of the stethoscope?

• A. Second intercostal space at the left sternal border
• B. Fifth intercostal space at the midclavicular line
• C. Fourth intercostal space at the left sternal border
• D. Fifth intercostal space at the left anterior axillary line

Correct answer: A

Rationale: The correct location to auscultate the pulmonary valve is the second intercostal space at the left sternal border. This area is where the pulmonary valve can best be heard due to its anatomical position. Choice B, the fifth intercostal space at the midclavicular line, is the location for auscultating the mitral valve. Choice C, the fourth intercostal space at the left sternal border, is the area for the tricuspid valve. Choice D, the fifth intercostal space at the left anterior axillary line, is the site for listening to the mitral valve as well. Therefore, option A is the correct choice for auscultating the pulmonary valve.

3. A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client’s ability to learn new dietary habits?

• A. The client's involvement in planning the change
• B. The cost of the dietary changes
• C. The availability of low-sodium foods
• D. The client’s previous dietary knowledge

Correct answer: D

Rationale: The client’s previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

4. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?

• A. Assault
• B. Battery
• C. False imprisonment
• D. Invasion of privacy

Correct answer: A

Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.

5. A healthcare professional is assessing a client’s oculomotor nerve functions. Which of the following actions should the healthcare professional take?

• A. Check the client’s pupillary reaction to light
• B. Ask the client to read print from the Snellen chart
• C. Ask the client to identify different scents
• D. Use cotton to lightly touch the client’s cornea

Correct answer: A

Rationale: Checking the client’s pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.

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