Nursing Elites

1. The healthcare professional observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the healthcare professional's intervention?

• A. The cuff wraps around the girth of the leg.
• B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
• C. The client is placed in a prone position.
• D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

Correct answer: B

Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. Auscultating the popliteal pulse with the cuff on the lower leg is incorrect as it may lead to an inaccurate reading. Placing the client in a prone position and wrapping the cuff around the girth of the leg are acceptable practices. A systolic reading that is 20 mm Hg higher in the lower extremity compared to the arm is expected due to the difference in blood pressure between the upper and lower parts of the body.

2. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

• A. Witness the client's signature on the permit.
• B. Answer the client's questions about the surgery.
• C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
• D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Correct answer: C

Rationale: The nurse should inform the surgeon promptly that the operative permit is not signed and the client has questions about the surgery. It is crucial for the surgeon to be aware of these issues as it is their responsibility to explain the procedure to the client and ensure that the necessary consent is obtained before proceeding with the surgery. Answering the client's questions directly (choice B) may not be appropriate as the surgeon is the one responsible for providing detailed information about the procedure. Witnessing the client's signature (choice A) is premature since the permit is not signed. Reassuring the client (choice D) is not the most appropriate action at this point; the priority is to involve the surgeon in addressing the unsigned permit and the client's questions.

3. The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?

• A. Document that the client responds to a painful stimulus.
• B. Observe the client's response to verbal stimulation.
• C. Place the client on seizure precautions for 24 hours.
• D. Report decorticate posturing to the healthcare provider.

Correct answer: A

Rationale: The client's response to a painful stimulus indicates a purposeful reaction, which should be accurately documented as per the assessment findings. This documentation is essential for ongoing monitoring and communication of the client's condition to the healthcare team.

4. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

• A. Encourage the client to see the clinic's grief counselor.
• B. Determine if the client has a family history of suicide attempts.
• C. Inquire about whether the life partner had AIDS.
• D. Consult with the healthcare provider about the client's need for antidepressant medications.

Correct answer: A

Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.

5. The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:

• A. Work on establishing rapport with the patient.
• B. Use humor to lighten emotionally charged topics of discussion.
• C. Empathize with the patient when the patient shares sad feelings.
• D. Demonstrate respect when discussing emotionally charged topics.

Correct answer: D

Rationale: In fostering a therapeutic relationship, demonstrating respect is essential as it helps the patient feel valued and understood. Respectful communication contributes to building trust and a safe environment for open and honest discussions.

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