Nursing Elites

1. During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?

• A. Fingertips
• B. Dorsal surface of the hand
• C. Ulnar portion of the hand
• D. Palmar surface of the hand

Correct answer: B

Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.

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. A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?

• A. The client lies on his side with the upper leg flexed
• B. The client lies on his back with his head lower than his feet
• C. The client lies on his abdomen with a pillow supporting his head
• D. The client is sitting up at a 90-degree angle

Correct answer: A

Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.

4. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?

• A. Respirations should be counted for 1 full minute.
• B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
• C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
• D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.

Correct answer: A

Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

5. A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When company arrives to visit the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak "perfect English."? What is this woman likely experiencing?

• A. Culture shock
• B. Cultural taboos
• C. Cultural unfamiliarity
• D. Culture disorientation

Correct answer: A

Rationale: The woman in the scenario is likely experiencing culture shock. Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group due to sudden strangeness, unfamiliarity, and incompatibility with the individual's perceptions and expectations. In this case, the woman's feelings of shyness and retreating due to not feeling confident in speaking 'perfect English' align with symptoms of culture shock. The other choices are incorrect: Cultural taboos refer to behaviors or actions that are prohibited within a particular culture; cultural unfamiliarity suggests a lack of knowledge about a specific culture, which is not the case here; and culture disorientation is not a commonly used term in cultural psychology, making it an incorrect option.

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