Nursing Elites

1. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?

• A. When the infant is sleeping
• B. At the end of the examination
• C. Before auscultation of the thorax
• D. At about the middle of the examination

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.

2. In which situation would the nurse use bimanual palpation technique?

• A. Palpating the thorax of an infant
• B. Palpating the kidneys and uterus
• C. Assessing pulsations and vibrations
• D. Assessing the presence of tenderness and pain

Correct answer: B

Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.

3. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?

• A. Ask the patient how he or she is feeling.
• B. Document the findings in the patient's record.
• C. Wait 10 minutes and auscultate the sound again.
• D. Ask another nurse to double-check the finding.

Correct answer: D

Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.

4. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?

• A. Trying prayer before seeking medical help
• B. Believing that illness is a punishment of sin
• C. Refusing to accept blood products as part of treatment
• D. Stating that a child's birth defect is the result of the parents' sins

Correct answer: C

Rationale: The concept of a cultural taboo involves practices that are forbidden or avoided within a particular culture. Refusing to accept blood products as part of treatment is a clear example of a cultural taboo, as some cultures or religions prohibit the use of blood products for medical purposes. This practice is deeply rooted in cultural beliefs and traditions. The other choices provided do not directly relate to cultural taboos. Trying prayer before seeking medical help, believing illness is a punishment of sin, and stating that a child's birth defect is the result of parents' sins are beliefs or actions based on religious or personal beliefs, but they do not specifically represent cultural taboos.

5. Which of the following bony landmarks is described as a large, blunt, irregularly shaped process found on the lateral aspect of the proximal femur?

• A. Tubercle
• B. Tuberosity
• C. Condyle
• D. Trochanter

Correct answer: D

Rationale: The correct answer is D: Trochanter. The Greater Trochanter is located on the lateral aspect of the proximal femur and is a large, blunt, irregularly shaped bony process. It serves as an important attachment site for many muscles of the legs, providing leverage and movement. Choice A, Tubercle, is a small rounded projection, usually for the attachment of a ligament or tendon. Choice B, Tuberosity, is a large rounded projection, also typically for muscle attachment. Choice C, Condyle, refers to a rounded articular surface at the end of a bone, usually involved in joints.

Similar Questions