Nursing Elites

1. The healthcare provider is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?

• A. Name the year. What season is this? (pause for answer after each question)
• B. Subtract 7 from 100 and then subtract 7 from that. (pause for answer) Now continue to subtract 7 from the new number.
• C. I am going to say the names of three things, and I want you to repeat them after me: blue, ball, pen.
• D. What is this on my wrist? (point to your watch) Then ask, What is the purpose of it?

Correct answer: B

Rationale: The correct answer is to ask the client to perform a calculation that involves working memory and processing skills. This question not only assesses the recent memory but also evaluates attention and executive functioning. The choice 'I am going to say the names of three things, and I want you to repeat them after me: blue, ball, pen' assesses immediate recall rather than recent memory. Asking about the current year or season tests orientation rather than recent memory. Inquiring about the watch and its purpose assesses comprehension and judgment rather than recent memory.

2. A patient with a cast on the right leg is being cared for by a nurse. Which of the following assessment findings would be most concerning for the nurse?

• A. The capillary refill time is 2 seconds
• B. The patient complains of itching and discomfort
• C. The cast has a foul-smelling odor
• D. The patient is on antibiotics

Correct answer: C

Rationale: A foul-smelling odor emanating from the cast is a concerning finding as it indicates the possibility of infection or the presence of a pressure ulcer. These conditions can lead to serious complications if not promptly addressed. It is crucial for the nurse to investigate further and take appropriate actions to prevent potential harm to the patient. The other options do not directly indicate a risk of infection or complications associated with the cast. Itching and discomfort are common complaints due to wearing a cast, and the patient being on antibiotics may be part of their treatment plan for an unrelated condition. Capillary refill time of 2 seconds is within the normal range and would not be a cause for immediate concern in this scenario.

3. The healthcare professional is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the healthcare professional expects to note which assessment finding?

• A. Severe and persistent diarrhea
• B. Intense pain in the toe
• C. Yellow-tinged sclera
• D. Headache

Correct answer: C

Rationale: In patients with sickle cell disease, severe generalized pain can be associated with vaso-occlusive crises, but yellow-tinged sclera is a common clinical finding related to sickle cell disease. This yellowing of the sclera, known as jaundice, occurs due to the release of bilirubin from damaged or destroyed red blood cells. Severe and persistent diarrhea is not a typical assessment finding in sickle cell disease. Intense pain in the toe may be associated with vaso-occlusive crisis but is not the expected assessment finding in this scenario. Headache is a common symptom in many conditions but is not specifically related to the assessment finding expected in a patient with sickle cell disease presenting with severe generalized pain.

4. When analyzing the results of the urinalysis collected preoperatively from a child with epispadias scheduled for surgical repair, which finding should the nurse most likely expect to note?

• A. Hematuria
• B. Proteinuria
• C. Bacteriuria
• D. Glucosuria

Correct answer: C

Rationale: Epispadias is a congenital defect characterized by the abnormal placement of the urethral orifice of the penis, often on the dorsum. This anatomical anomaly predisposes individuals to bacterial entry into the urinary tract, leading to bacteriuria. Hematuria, proteinuria, and glucosuria are not typically associated with epispadias. Hematuria refers to the presence of blood in the urine, proteinuria indicates protein in the urine, and glucosuria is the presence of glucose in the urine, none of which are commonly seen in epispadias.

5. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?

• A. Assist the patient to splint the chest when coughing.
• B. Teach the patient about the need for fluid intake.
• C. Encourage the patient to wear the nasal oxygen cannula.
• D. Instruct the patient on the pursed lip breathing technique.

Correct answer: A

Rationale: Assisting the patient to splint the chest when coughing is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia, rhonchi, and thick sputum. Splinting the chest helps reduce pain during coughing and increases the effectiveness of clearing secretions. Teaching the patient about the need for fluid intake is important as it helps liquefy secretions, aiding in easier clearance. Encouraging the patient to wear a nasal oxygen cannula may improve gas exchange but does not directly promote airway clearance. Instructing the patient on the pursed lip breathing technique is beneficial for improving gas exchange in patients with COPD but does not directly aid in airway clearance in a patient with bacterial pneumonia and thick sputum.

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