Nursing Elites

1. During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?

• A. Wash hands and then contact the physician.
• B. Continue to examine the ulceration and then wash hands.
• C. Wash hands, put on gloves, and continue with the examination of the ulceration.
• D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.

Correct answer: C

Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.

2. When a patient refuses to believe a terminal diagnosis, they are exhibiting:

• A. Regression
• B. Mourning
• C. Denial
• D. Rationalization

Correct answer: C

Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.

3. What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?

• A. Germs and viruses
• B. Supernatural forces
• C. Eating imbalanced (hot/cold) foods
• D. Imbalance within his or her spiritual nature

Correct answer: B

Rationale: Individuals who adhere to the magicoreligious theory of illness and disease attribute the cause of illness to supernatural forces. In this perspective, the world is perceived as governed by supernatural forces that influence the well-being of individuals. The belief is that these forces can bring about both good and evil outcomes. Choices A, C, and D are incorrect. Germs and viruses are associated with the biomedical theory of illness. Eating imbalanced hot or cold foods is linked to the yin/yang naturalist theory. Imbalance within one's spiritual nature is not a recognized cause of illness in any of the established theories of illness.

4. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

• A. These readings are a normal response and attributable to changes in the patient's position.
• B. The change in blood pressure readings is called orthostatic hypotension.
• C. The blood pressure reading in the lying position is within normal limits.
• D. The change in blood pressure readings is considered within normal limits for the patient's age.

Correct answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of ³20 mm Hg or ³10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.

5. Where is the pulse point located on the top of the foot?

• A. the dorsalis pedis
• B. This is the pulse point checked in patients with peripheral vascular problems.
• C. This pulse point may be absent in some patients due to a congenital anomaly.
• D. All of the above.

Correct answer: D

Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.

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