Nursing Elites

1. Which technique of assessment will the healthcare provider use to determine the presence of crepitus, swelling, and pulsations?

• A. Palpation
• B. Inspection
• C. Percussion
• D. Auscultation

Correct answer: A

Rationale: Palpation involves using the sense of touch to assess various characteristics such as texture, temperature, moisture, organ location and size, as well as detecting swelling, pulsations, vibrations, rigidity, crepitus, lumps, masses, and tenderness or pain. In this scenario, the healthcare provider would utilize palpation to physically feel for crepitus, swelling, and pulsations. Inspection primarily relies on visual assessment, percussion involves assessing through palpable vibrations and audible sounds, and auscultation uses the sense of hearing. Therefore, the correct answer is palpation for assessing the presence of crepitus, swelling, and pulsations.

2. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.

• A. Client has an actual health problem
• B. Client has a wellness diagnosis
• C. Collaborative health problem needs to be written
• D. Possible nursing diagnosis exists

Correct answer: B

Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.

3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating, "the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society,"? reflects which term?

• A. Norms
• B. Culture
• C. Ethnicity
• D. Assimilation

Correct answer: B

Rationale: The term that best fits the provided definition, which includes knowledge, beliefs, customs, and skills acquired by members of a society, is 'Culture.' Culture is a broad concept encompassing various aspects of a society's way of life. Norms refer to typical behaviors or rules within a society. Ethnicity pertains to shared traits among a social group, such as origin, religion, language, and traditions. Assimilation involves adopting the dominant culture's characteristics, often through integration or conformity.

4. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?

• A. Rigor mortis
• B. Postmortem decomposition
• C. Algor mortis
• D. Livor mortis

Correct answer: C

Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.

5. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

• A. Tell the patient, 'Please remain silent while I count your number of breaths.'
• B. Count respirations at the same time you are counting the pulse rate
• C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
• D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

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