Nursing Elites

1. When planning a cultural assessment, what component should the nurse include?

• A. Family history
• B. Chief complaint
• C. Medical history
• D. Health practices

Correct answer: D

Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.

2. During a general survey of a patient, which finding is considered normal?

• A. Body mass index (BMI) of 20.
• B. When standing, the patient's base is narrow.
• C. The patient appears older than their stated age.
• D. Arm span (fingertip to fingertip) is greater than the height.

Correct answer: A

Rationale: A body mass index (BMI) of 20 is considered normal as the range for a normal BMI is between 19-24. When standing, a patient's base should be wide for stability and proper weight distribution. An older appearance than the stated age may indicate a history of chronic illness or chronic alcoholism. In a general survey, the patient's arm span (fingertip to fingertip) should approximately equal the patient's height. An arm span greater than the height may suggest Marfan syndrome. Therefore, the correct choice is a normal BMI of 20, which falls within the healthy range. Choices B, C, and D all describe abnormal findings that may indicate underlying health conditions or syndromes.

3. A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at the time of admission?

• A. Place a padded tongue depressor at the head of the bed.
• B. Pad the bed with blankets.
• C. Inform the client about the importance of wearing a medical identification tag.
• D. Teach the client about seizures.

Correct answer: B

Rationale: The most essential measure when admitting a client who had a seizure is to pad the bed with blankets (Option B). This is crucial to prevent injury in case of another seizure. Placing a padded tongue depressor at the head of the bed (Option A) is incorrect as current nursing guidelines advise against putting anything in the client's mouth during a seizure. Informing the client about wearing a medical identification tag (Option C) and teaching the client about seizures (Option D) are important but are more relevant once the cause of the seizure is known. It's crucial to remember that not all seizures are classified as epilepsy.

4. For a healthcare worker under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?

• A. At least a 15-second scrub with plain soap and water
• B. At least a 23-minute scrub with an antimicrobial soap
• C. Use of an alcohol-based antiseptic hand-rub
• D. Wearing a mask when scrubbing

Correct answer: C

Rationale: Effective hand hygiene between patients for a healthcare worker with unsoiled hands involves using an alcohol-based antiseptic hand rub. This method is sufficient for cleaning hands that are not visibly soiled. The use of an antimicrobial soap or a prolonged scrubbing time is unnecessary and not recommended in this scenario. Wearing a mask is not required for routine hand hygiene and does not contribute to effective hand cleaning.

5. Madge is a 91-year-old nursing home resident with a history of dementia and atrial fibrillation who has been admitted to the hospital for treatment of pneumonia. As you are performing her bed bath, you note bruising around her breasts and genital area. What potential issue should be of major concern in Madge's situation?

• A. Idiopathic thrombocytopenic purpura (ITP)
• B. Embolic stroke
• C. Sexual abuse
• D. Nursing home-acquired pneumonia (NHAP)

Correct answer: C

Rationale: Bruising around the breasts and genitals should trigger concern for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on behalf of vulnerable populations, such as the elderly. According to the National Center on Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. In this scenario, given Madge's age, history of dementia, and the presence of unexplained bruising in sensitive areas, sexual abuse must be considered as a major concern. Idiopathic thrombocytopenic purpura (ITP) is a platelet disorder that presents with excessive bruising and bleeding, but it is less likely in this case as the bruising pattern is suggestive of a different cause. Embolic stroke is a neurological condition that typically presents with sudden onset neurological deficits and is not related to the observed bruising. Nursing home-acquired pneumonia (NHAP) is a common issue in elderly residents but would not manifest as bruising in specific areas like the breasts and genitals.

Similar Questions