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. During a client interview, which of the following leading questions should the nurse avoid asking?

• A. What medication do you take at home?
• B. You are really excited about the plastic surgery, aren't you?
• C. Were you aware I've had this same type of surgery?
• D. What would you like to talk about?

Correct answer: B

Rationale: The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.

3. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

• A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
• B. A teenager who suffered singed facial hair while camping
• C. An elderly client with complaints of frequent liquid brown-colored stools
• D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

4. The nurse is reviewing concepts related to one's heritage and beliefs. Which concept refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe?

• A. Culture
• B. Religion
• C. Ethnicity
• D. Spirituality

Correct answer: B

Rationale: Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services. Religion is a shared experience of spirituality or the values, beliefs, and practices into which people are either born or that they may adopt to meet their personal spiritual needs through communal actions, such as religious affiliation, attendance and participation in a religious institution, prayer, or meditation, and religious practices. Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It does not refer to a belief in a divine or superhuman power. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others. Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence.

5. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse prioritize first on the list to be discharged in order to make a room available for a new admission?

• A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
• B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
• C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
• D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.

Correct answer: A

Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time. Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition. Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation. Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.

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