Nursing Elites

1. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

• A. Diastolic blood pressure may not be heard.
• B. Diastolic blood pressure may be falsely low.
• C. Systolic blood pressure may be falsely low.
• D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

2. Intermittent fevers are:

• A. fevers which come and go.
• B. fevers which rise and fall but are always considered above the patient's average temperature.
• C. fevers which fluctuate more than three degrees and never return to normal.
• D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

3. What action by the nurse is appropriate when examining a 16-year-old male teenager?

• A. Discuss health teaching with the teenager to promote wellness.
• B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
• C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
• D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.

Correct answer: D

Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.

4. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?

• A. Ask the parent to place the child on the examining table.
• B. Have the parent remove all of the child's clothing before the examination.
• C. Allow the child to keep a security object such as a toy or blanket during the examination.
• D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Correct answer: C

Rationale: The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.

5. Which type of shock is related to low blood volume?

• A. Psychogenic
• B. Cardiogenic
• C. Anaphylactic
• D. Hemorrhagic

Correct answer: D

Rationale: Hemorrhagic shock, also known as hypovolemic shock, is directly related to low blood volume due to significant blood loss. In hemorrhagic shock, the body's circulating blood volume is reduced, leading to inadequate perfusion of tissues and organs. Psychogenic shock is caused by emotional distress, not blood volume changes. Cardiogenic shock results from heart failure, not low blood volume. Anaphylactic shock is due to a severe allergic reaction, not a reduction in blood volume.

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