Nursing Elites

1. When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?

• A. The nurse speaks loudly.
• B. The nurse allows additional time after each instruction to allow the client to process.
• C. The nurse provides supplemental written resources.
• D. The nurse breaks up the education into multiple shorter sessions.

Correct answer: A

Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.

2. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

• A. administering immune globulin intravenously
• B. assessing the extremities for edema, redness, and desquamation every 8 hours
• C. explaining progression of the disease to the client and their family
• D. assessing heart sounds and rhythm

Correct answer: C

Rationale: Educating the client and their family about the progression of Kawasaki disease is crucial for promoting a positive body image. By explaining when symptoms are expected to improve and resolve, the client and family can better understand that there will be no permanent disruption in physical appearance that could negatively impact body image. Administering immune globulin intravenously is a treatment for Kawasaki disease but does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly address body image concerns. Assessing heart sounds and rhythm is essential for evaluating cardiac effects of Kawasaki disease but is not the most direct measure for promoting a positive body image.

3. A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:

• A. Gravida 2, para 6
• B. Gravida 6, para 2
• C. Gravida 3, para 6
• D. Gravida 2, para 2

Correct answer: B

Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Therefore, this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). In this case, the correct answer is Gravida 6, para 2. Choices A, C, and D are incorrect as they do not accurately reflect the information provided. Pregnancy outcomes are often described using the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). Applying this to the client's history, the GTPAL would be G = 6, T = 1, P = 1, A = 3, L = 2, which further confirms the correct answer.

4. A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?

• A. Dull sounds
• B. Hyperresonance sounds
• C. Hypoactive bowel sounds
• D. An absence of bowel sounds

Correct answer: A

Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.

5. A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets the client's results in which way?

• A. The client is legally blind.
• B. The client has normal vision.
• C. The client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.
• D. The client can read at a distance of 80 feet what a client with normal vision can read at 20 feet.

Correct answer: D

Rationale: When interpreting visual acuity testing results using the Snellen chart, the recorded numeric fraction represents the distance the client is standing from the chart and the distance a normal eye could read that particular line. A reading of 20/80 means that the client can read at 20 feet what a client with normal vision can read at 80 feet. This indicates visual impairment but does not meet the criteria for legal blindness, which is defined as best-corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20. Therefore, the correct interpretation is that the client can read at a distance of 80 feet what a client with normal vision can read at 20 feet. Choice A is incorrect because 20/80 does not meet the criteria for legal blindness. Choice B is incorrect as the client's vision is impaired. Choice C is incorrect because it reverses the interpretation of the fraction.

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