Nursing Elites

1. During a client interview, which of the following leading questions should the nurse avoid asking?

• A. What medication do you take at home?
• B. You are really excited about the plastic surgery, aren't you?
• C. Were you aware I've had this same type of surgery?
• D. What would you like to talk about?

Correct answer: B

Rationale: The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.

2. Which gland of the endocrine system secretes a hormone that assists with the sleep/wake cycle?

• A. Pituitary
• B. Pineal
• C. Pancreas
• D. Hypothalamus

Correct answer: B

Rationale: The correct answer is the Pineal gland. The Pineal gland, located in the brain, secretes melatonin, which plays a crucial role in regulating the sleep/wake cycle in response to exposure to light. The Pituitary gland (Choice A) secretes various hormones but not specifically related to the sleep/wake cycle. The Pancreas (Choice C) secretes insulin and digestive enzymes, not hormones related to the sleep/wake cycle. The Hypothalamus (Choice D) is involved in regulating many bodily functions, including hormone secretion, but it does not directly secrete the hormone that regulates the sleep/wake cycle.

3. The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature"?36�C; pulse"?48 beats per minute; respirations"?14 breaths per minute; blood pressure"?104/68 mm Hg. Which statement is true concerning these results?

• A. The patient is experiencing bradycardia.
• B. These are normal vital signs for a healthy, athletic adult.
• C. The patient's pulse rate is not normal"?no action is required.
• D. The patient's next clinic visit should occur as scheduled.

Correct answer: B

Rationale: The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness. Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.

4. When cleansing the genital area during perineal care, the nurse should _____________.

• A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
• B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
• C. cleanse the rectal area first and then clean the patient's genital area.
• D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.

Correct answer: B

Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.

5. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

• A. A little, a moderate amount, or all of the meal
• B. 50 cc, 100 cc, or 500 cc of the meal
• C. 25%, 50%, or 100% of the meal
• D. Either A or C

Correct answer: C

Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.

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