Nursing Elites

1. When performing an abdominal assessment, what is the correct order of the tasks?

• A. inspect, percuss, palpate, auscultate
• B. inspect, palpate, percuss, auscultate
• C. inspect, auscultate, percuss, palpate
• D. inspect, palpate, auscultate, percuss

Correct answer: C

Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.

2. A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider?

• A. "If I go from a very bright room to a very dark room, I have some trouble adjusting."
• B. "I have to hold my newspaper farther and farther away from me when I read."
• C. "I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me."
• D. "It looks like I have a blank spot in the middle of what I'm trying to see."

Correct answer: D

Rationale: The correct answer is "It looks like I have a blank spot in the middle of what I'm trying to see." Seeing blank spots in the middle of an object is a sign of central vision loss, which is a symptom of macular degeneration. Macular degeneration is a serious condition that requires immediate discussion with a healthcare provider to prevent further vision loss. Choice A, mentioning difficulty adjusting between bright and dark rooms, is a common issue related to changes in lighting and not a cause for immediate concern. Choice B, having to hold objects farther away when reading, is indicative of presbyopia, a normal age-related change in vision. Choice C, experiencing slight changes in color perception, is also a common age-related change and not an urgent issue that necessitates immediate discussion with a healthcare provider.

3. Which condition is associated with inadequate intake of vitamin C?

• A. rickets
• B. marasmus
• C. kwashiorkor
• D. scurvy

Correct answer: D

Rationale: Scurvy is indeed associated with inadequate intake of vitamin C. Vitamin C deficiency leads to scurvy, which is characterized by weakness, anemia, gum disease, and skin hemorrhages. Choices A, B, and C are incorrect because rickets is caused by vitamin D deficiency, marasmus is due to severe malnutrition leading to wasting, and kwashiorkor is a form of severe protein-energy malnutrition.

4. When a 25-year-old client complains of chest congestion and cough after previously presenting with cold symptoms, what data should the nurse collect?

• A. Data related to follow-up care
• B. A complete health database
• C. Data related to the respiratory system
• D. Data related to the treatment for the cold

Correct answer: C

Rationale: In this case, the nurse should collect data related to the respiratory system since the client is presenting with symptoms like chest congestion and cough, indicating a respiratory issue. Focusing on the respiratory system will help gather pertinent information to assess the current problem comprehensively. A complete health database involves a detailed health history and full physical examination, which is beyond the immediate scope of the presenting issue. Data related to follow-up care is premature as the primary focus should be on assessing the current respiratory symptoms. Data related to the treatment for the cold is not the priority at this stage, as understanding the underlying respiratory problem is crucial for appropriate intervention.

5. Which of the following statements is correct about Maslow's hierarchy of needs?

• A. There are psychosocial interventions that may be applicable to all of the levels.
• B. There are physical interventions that may be applicable to all of the levels.
• C. Two of the levels may require physical intervention while four of the levels may require psychosocial intervention.
• D. Four of the levels may require physical intervention, while two of the levels may require psychosocial intervention.

Correct answer: C

Rationale: The correct statement about Maslow's hierarchy of needs is that two of the levels may require physical intervention while four of the levels may require psychosocial intervention. Maslow's theory suggests that physiological and safety needs are more basic and may require physical interventions, while social, esteem, and self-actualization needs are more psychosocial. Choices A and B are incorrect as they wrongly suggest that all levels may require only one type of intervention. Choice D is incorrect because it inaccurately represents the balance of physical and psychosocial interventions in Maslow's hierarchy of needs.

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