Nursing Elites

1. When ambulating a frail, older adult client, the nurse should:

• A. Use the transfer belt if the client is unsteady
• B. Walk beside the client without support
• C. Encourage the client to use a walker
• D. Hold the client's arm for support

Correct answer: A

Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.

2. When planning interventions for a group of clients who are obese, what can the nurse do to improve their commitment to a long-term goal of weight loss?

• A. Developing a strict diet plan
• B. Attempting to develop the clients’ self-motivation
• C. Providing frequent rewards
• D. Encouraging group exercise

Correct answer: B

Rationale: To improve clients' commitment to a long-term goal of weight loss, attempting to develop their self-motivation is crucial. Self-motivation is essential for sustaining behavior changes over time. Providing a strict diet plan (choice A) may not address the root motivation needed for long-term success. While rewards (choice C) can be motivating, relying solely on external rewards may not foster the intrinsic motivation required for sustained weight loss. Encouraging group exercise (choice D) is beneficial, but without addressing individual motivation, it may not lead to long-term commitment to weight loss goals.

3. When assessing a client's neurologic system, what should the nurse ask the client to close their eyes and identify?

• A. A word whispered by the nurse 30cm from the ear
• B. A number traced on the palm of the hand
• C. The vibration of a tuning fork placed on the foot
• D. A familiar object placed in the hand

Correct answer: B

Rationale: When a nurse asks a client to identify a number traced on the palm of the hand with their eyes closed, it assesses the client's ability to perceive touch sensations. This test specifically evaluates the tactile discrimination of the client. The other options do not test the client's ability to identify sensations accurately with eyes closed. Option A tests auditory perception, option C tests vibratory sense, and option D tests object recognition but not tactile discrimination, making them incorrect choices.

4. During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?

• A. Position the client 6.1 m (20 ft) away from the Snellen chart
• B. Instruct the client to follow a finger through the six cardinal positions of gaze
• C. Ask the client to cover their right eye during assessment of the left eye
• D. Hold a finger 46 cm (18 inches) away from the client's eye

Correct answer: B

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.

5. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by elevated body temperature, which can lead to hypotension (low blood pressure) due to dehydration and vasodilation. Bradycardia (slow heart rate) and clammy skin are not typical findings in heat stroke. Bradypnea (slow breathing) is also not a common feature of heat stroke. Therefore, hypotension is the most likely cardiovascular manifestation seen in a client with heat stroke.

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