Nursing Elites

1. During a physical assessment on a toddler, what should be the first action?

• A. Perform traumatic procedures
• B. Use minimal physical contact
• C. Proceed from head to toe
• D. Explain the exam in detail

Correct answer: B

Rationale: The correct first action when performing a physical assessment on a toddler is to use minimal physical contact. This approach helps the toddler become comfortable and reduces anxiety during the assessment. Traumatic procedures (Choice A) should never be the first action as they can cause distress. Proceeding from head to toe (Choice C) is a common sequence in physical assessments but does not address the initial need to establish trust and comfort. Explaining the exam in detail (Choice D) is important but should come after establishing a rapport through minimal physical contact.

2. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.

3. When assessing a client’s heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a:

• A. Pericardial friction rub
• B. Heart murmur
• C. S3 heart sound
• D. S4 heart sound

Correct answer: A

Rationale: A pericardial friction rub is characterized by a scratching sound that occurs during both systole and diastole. It becomes more distinct when the client is sitting up and leaning forward. This indicates an inflammation of the pericardial sac rubbing against the layers of the heart. Heart murmurs (choice B) are abnormal heart sounds caused by turbulent blood flow, not by friction like in a pericardial rub. S3 and S4 heart sounds (choices C and D) are additional heart sounds related to abnormal ventricular filling, not to pericardial friction rubs.

4. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the nurse to take?

• A. Monitor the client's blood glucose level.
• B. Encourage the client to increase fluid intake.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: A

Rationale: The most critical action for the nurse to take when a client with diabetes mellitus presents with symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps in assessing the client's current glycemic status and guides further interventions. Encouraging increased fluid intake (Choice B) may be beneficial in managing dehydration caused by polyuria, but it does not address the underlying cause of hyperglycemia. Administering insulin as prescribed (Choice C) may be necessary based on the blood glucose monitoring results, but monitoring should precede any medication administration. Assessing the client's urine output (Choice D) is important but does not directly address the primary concern of evaluating and managing hyperglycemia in a client with diabetes.

5. The healthcare provider is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include...

• A. Notify the surgeon of the client’s concern
• B. Have the client sign a new surgical permit
• C. Add the client’s concern to the permit
• D. Inform the surgeon about the client’s concern

Correct answer: D

Rationale: In this scenario, the best course of action is to inform the surgeon about the client's concern. This action ensures that the surgeon is aware of the client's specific request or concern related to the procedure. By directly involving the surgeon, the client's preferences or needs can be addressed effectively, potentially avoiding any misunderstanding or dissatisfaction. Choice A has been corrected to 'Notify the surgeon of the client’s concern' as the operating room staff may not have the authority to make changes to the permit. Having the client sign a new surgical permit (Choice B) may not be necessary if the concern can be addressed by informing the surgeon, making Choice B less efficient. Adding the client’s concern to the permit (Choice C) without consulting the surgeon may not align with the standard procedure and could lead to confusion or legal issues if the surgeon is not aware of the client’s specific requests.

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