Nursing Elites

1. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

• A. The child is asked to undress from the waist up.
• B. The head is examined before the thorax, abdomen, and genitalia.
• C. The nurse should keep in mind that a child at this age will have a sense of modesty.
• D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.

Correct answer: C

Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.

2. During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?

• A. Behavior
• B. Cognition
• C. Affect and mood
• D. Perceptual disturbances

Correct answer: B

Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.

3. Which of the following is an example of physical abuse?

• A. A slap to the person's hand
• B. Threatening the person
• C. Ignoring and isolating a person
• D. Leaving a patient soiled for hours

Correct answer: A

Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.

4. An older adult patient brought to the emergency department by a family member is wandering outside, saying, "I can't find my way home."? The patient is confused and unable to answer questions. What is the nurse's best action?

• A. Document the patient's mental status and obtain other assessment data from the family member.
• B. Record the patient's answers to questions on the nursing assessment form.
• C. Ask an advanced practice nurse to perform the assessment interview.
• D. Call for a mental health advocate to maintain the patient's rights.

Correct answer: A

Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.

5. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?

• A. Get the nurse who is caring for the patient.
• B. Tell the nurse that the patient has had another seizure.
• C. Observe the patient for any injuries and call out for help.
• D. Nothing. This patient is not one of your assignments.

Correct answer: C

Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.

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