Nursing Elites

1. What is the primary theory that explains a family's concept of health and illness?

• A. Health Belief Model
• B. Education-School-Completing Factor
• C. Family Health Expert Factor
• D. Disconnected Family Factor

Correct answer: A

Rationale: The correct answer is the Health Belief Model. This model explains a family's concept of health and illness by focusing on readiness factors, perceived susceptibility, and seriousness of health problems, and positive motivation for wellness. The Health Belief Model is widely used in healthcare to understand and predict health behaviors. Choices B, C, and D are incorrect as they do not specifically address how a family perceives health and illness. The Health Belief Model is the most appropriate choice as it is specifically designed to explain individual and family beliefs and behaviors related to health and illness.

2. A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?

• A. Smiling
• B. Clenching the teeth
• C. Shrugging the shoulders against the nurse's resistance
• D. Identifying by taste a substance placed on the back of the tongue

Correct answer: C

Rationale: To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.

3. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

• A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
• B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
• C. The organ procurement organization makes the decision regarding which organs to harvest.
• D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.

Correct answer: A

Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.

4. The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?

• A. Health promotion
• B. Secondary prevention
• C. Tertiary prevention
• D. Primary prevention

Correct answer: B

Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke. Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia. Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them. Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.

5. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?

• A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
• B. taking a cool shower and drinking a hot cup of tea
• C. watching TV nightly until midnight
• D. getting a back rub and drinking a glass of warm milk

Correct answer: D

Rationale: The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.

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