Nursing Elites

1. What is the MOST ACCURATE statement regarding the ESR test?

• A. The results are diagnostic for certain conditions.
• B. Abnormal results are indicative of a potentially fatal illness.
• C. Abnormal results should be followed by additional testing.
• D. Results are reported in millimeters per hour.

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

2. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?

• A. Discomfort
• B. Deficit
• C. Feeding
• D. Fractured wrists

Correct answer: D

Rationale: The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor. Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.

3. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?

• A. Ask the parent to place the child on the examining table.
• B. Have the parent remove all of the child's clothing before the examination.
• C. Allow the child to keep a security object such as a toy or blanket during the examination.
• D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Correct answer: C

Rationale: The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.

4. What message is a patient sending when displaying the following body language: Slumped shoulders, grimace, and stiff joints?

• A. Anger
• B. Aloofness
• C. Empathy
• D. Depression

Correct answer: A

Rationale: Body language is a powerful form of non-verbal communication that can convey various emotions. In this scenario, the patient's slumped shoulders, grimace, and stiff joints suggest a negative emotional state. Anger is the correct answer because grimacing and tense posture are commonly associated with anger. Choice B, 'Aloofness,' is incorrect as aloofness is more related to disinterest or detachment, which is not indicated by the described body language. Choice C, 'Empathy,' is incorrect as the body language described does not align with expressing understanding or compassion towards others. Choice D, 'Depression,' is incorrect as while depression can also manifest through body language, the specific cues given in the scenario lean more towards anger than depression.

5. The client starting an exercise program will progress to walking a 20-minute mile in one month.

• A. Client will walk quickly three times a day
• B. Client will be able to walk a mile
• C. Client will have no alteration in breathing during the walk
• D. Client will progress to walking a 20-minute mile in one month

Correct answer: D

Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. Choice A lacks specificity and does not mention a target time or goal. Choice B is vague and does not provide a specific target for improvement. Choice C focuses on a negative outcome (no alteration) rather than a positive goal. The correct answer, Choice D, is specific, measurable, and time-bound, making it a suitable outcome statement for a client starting an exercise program.

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