Nursing Elites

1. When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?

• A. The body temperature of the older adult is lower than that of a younger adult.
• B. An older adult's body temperature is approximately the same as that of a young child.
• C. Body temperature varies based on the type of thermometer used.
• D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.

Correct answer: A

Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2�C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.

2. In a patient with acromegaly, which assessment finding will the nurse expect to find?

• A. Sternal deformity and hyperextensible joints
• B. Growth retardation and a delayed onset of puberty
• C. Overgrowth of bone in the face, head, hands, and feet
• D. Increased height and weight and delayed sexual development

Correct answer: C

Rationale: Acromegaly is a condition characterized by excessive secretion of growth hormone in adulthood after normal body growth completion. This hormonal excess leads to overgrowth of bones in the face, head, hands, and feet; however, there is no significant change in height. Stating sternal deformity and hyperextensible joints is incorrect as they are characteristic findings of Marfan syndrome. Growth retardation and delayed onset of puberty are not typical of acromegaly but are seen in hypopituitary dwarfism. Increased height, weight, and delayed sexual development are features of gigantism, not acromegaly. Therefore, the correct assessment finding in a patient with acromegaly would be overgrowth of bone in the face, head, hands, and feet.

3. When should you wear gloves?

• A. preparing infant formula for a newborn baby
• B. transferring breast milk into a baby bottle
• C. knocking on a patient's door
• D. opening a patient's door

Correct answer: B

Rationale: You must wear gloves when transferring breast milk into a baby bottle because breast milk is considered a bodily fluid. It is essential to avoid direct contact to prevent contamination. When preparing infant formula, gloves are not required as formula is not a bodily fluid. Knocking on or opening a patient's door does not involve direct contact with bodily fluids, so gloves are unnecessary in those situations.

4. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

• A. Angina at rest
• B. Thrombus formation
• C. Dizziness
• D. Falling blood pressure

Correct answer: B

Rationale: Thrombus formation is a critical complication of cardiac catheterization that the nurse should monitor for in the initial 24 hours after the procedure. A thrombus can form in the blood vessels, obstructing blood flow and potentially leading to serious consequences such as embolism or organ ischemia. While angina at rest, dizziness, and falling blood pressure are potential complications following cardiac catheterization, they are not typically associated with the immediate post-procedural period. Monitoring for thrombus formation is essential to ensure early detection and intervention, which can prevent serious complications.

5. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

• A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
• B. Obtain a thorough history and physical assessment from the patient's family member.
• C. Immediately perform a complete history and physical assessment to obtain baseline information.
• D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.

Correct answer: D

Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.

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