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 nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?

• A. Normally heard in the lungs
• B. Hollow sounds heard over the trachea and larynx
• C. Rustling sounds heard over the peripheral lung fields
• D. Abnormal sounds that should not be heard in the lungs

Correct answer: D

Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.

3. An appraisal of self-care practices involves an assessment of:

• A. all diagnostic tests.
• B. home treatment practices, including nurse visits for the sick or disabled.
• C. the family's capability to get health insurance.
• D. caregiving needs and the potential for strain.

Correct answer: D

Rationale: An appraisal of self-care practices focuses on assessing caregiving needs and the potential for strain. This involves evaluating the support system in place for individuals requiring care, the level of strain experienced by caregivers, and the overall impact of caregiving responsibilities on both the caregiver and the care recipient. The other options presented do not directly relate to the assessment of self-care practices. Diagnostic tests, home treatment practices, and the family's capability to obtain health insurance are important aspects of healthcare but do not specifically pertain to the evaluation of self-care practices.

4. A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which action does the nurse take to help ensure the success of the interview?

• A. Ensuring that the room is private
• B. Having the client sit across from the nurse without a desk or table between them
• C. Maintaining a distance of 4 to 5 feet between the nurse and client
• D. Adjusting the room lighting to ensure it is comfortable and conducive for the client

Correct answer: A

Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained to avoid interruptions during the interview. This helps create a safe space for the client to share sensitive information. Having the client sit across from the nurse without a desk or table between them is also important to promote open communication and build rapport. Maintaining a distance of 4 to 5 feet from the client respects their personal space and helps prevent the client from feeling overwhelmed. While adjusting the room lighting is beneficial for creating a comfortable atmosphere, ensuring privacy is crucial for establishing trust and confidentiality. Therefore, ensuring that the room is private is crucial for the success of the interview, making choice A the correct answer. Choices B, C, and D are incorrect as they do not directly address the importance of privacy in creating a conducive environment for the interview.

5. When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?

• A. That the cervix appears violet
• B. That cervical softening is present
• C. A positive sign of pregnancy
• D. A thinning of the cervix

Correct answer: A

Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one. Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.

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