Nursing Elites

1. Which of the following is an anthropometric measurement?

• A. Blood pressure
• B. Temperature
• C. Pulse Rate
• D. Weight

Correct answer: D

Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.

2. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?

• A. The nurse ties the restraints in a square knot to prevent the client from untying them
• B. The restraints are attached to a movable portion of the bed
• C. The padded side of the restraint is applied next to the skin of the wrist
• D. The nurse assesses the client's distal circulation every 24 hours

Correct answer: C

Rationale: Restraint use must prioritize the safety of the client. When applying restraints around the wrists, the padded side should be placed against the skin to help prevent skin breakdown. Additionally, restraints should be secured in quick-release knots to ensure they can be removed rapidly in case of an emergency. Choice A is incorrect as restraints should not be tied in a way that could prevent quick removal. Choice B is incorrect because restraints should not be attached to a movable part of the bed to avoid unintentional movement. Choice D is incorrect as assessing distal circulation is important but is not directly related to the safe application of restraints.

3. A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

• A. A middle-aged client who says, "I took too many diet pills"? and "my heart feels like it is racing out of my chest."?
• B. A young adult who says, "I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?"?
• C. An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 11.
• D. An elderly client who reports having taken a "large crack hit"? 10 minutes prior to walking into the emergency room.

Correct answer: C

Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients. Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention. Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention. Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention. Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.

4. Which of the following scenarios provides an example of a healthcare professional overcoming a barrier to communication?

• A. A healthcare professional uses a visual aid to explain how to conduct a fingerstick glucose test to a patient with visual impairment.
• B. A healthcare professional writes down instructions for a patient who is hearing impaired.
• C. A healthcare professional raises their voice when speaking to a patient who does not speak English.
• D. A healthcare professional uses medical jargon while conversing with a minor.

Correct answer: B

Rationale: Overcoming barriers to communication in healthcare involves utilizing methods of communication that are accessible and understandable to the recipient. In the scenario provided, writing down instructions for a patient who is hearing impaired is an effective way to ensure clear communication and overcome the obstacle of hearing impairment. This method allows the patient to visually comprehend the information provided. Choice A is incorrect because using a visual aid for a visually impaired patient, not a hearing-impaired patient, would be more appropriate. Choice C is incorrect as raising one's voice does not address the language barrier effectively and may not enhance understanding. Choice D is incorrect as using complex medical terms with a minor may lead to confusion and hinder effective communication.

5. Which of these specific measurements is the best index of a child's general health?

• A. Body mass index
• B. Height and weight
• C. Head circumference
• D. Chest circumference

Correct answer: B

Rationale: Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status. Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.

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