Nursing Elites

1. Which of the following is the most likely cause of constipation in a client?

• A. Postponing bowel movement when the urge to defecate occurs
• B. Intestinal infection
• C. Antibiotic use
• D. Food allergies

Correct answer: A

Rationale: The correct answer is to postpone bowel movement when the urge to defecate occurs. Clients who delay bowel movements by ignoring the urge to defecate or not evacuating promptly, such as in situations where they are not near a bathroom, are at higher risk of developing constipation. This behavior leads to a decrease in bowel movement frequency, slowed intestinal motility, and increased fecal water absorption, resulting in hard, dry stools that are difficult to pass. Intestinal infection (choice B), antibiotic use (choice C), and food allergies (choice D) are less likely to be direct causes of constipation compared to postponing bowel movements.

2. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?

• A. Ask the patient how he or she is feeling.
• B. Document the findings in the patient's record.
• C. Wait 10 minutes and auscultate the sound again.
• D. Ask another nurse to double-check the finding.

Correct answer: D

Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.

3. In a 68-year-old man, a gradual loss of hearing is known as _____________.

• A. presbycusis
• B. xerostomia
• C. myopia
• D. presbyopia

Correct answer: A

Rationale: The correct answer is 'presbycusis.' Presbycusis is the age-related gradual loss of hearing ability, commonly seen in the elderly population. Xerostomia refers to dry mouth, myopia is nearsightedness, and presbyopia is the age-related loss of the eye's ability to focus on close objects. Given Mr. Roberts' age and symptom of gradual hearing loss, presbycusis is the most likely diagnosis. Xerostomia, myopia, and presbyopia do not match the sensory change described in the question, making them incorrect choices.

4. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

• A. Tell the patient, 'Please remain silent while I count your number of breaths.'
• B. Count respirations at the same time you are counting the pulse rate
• C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
• D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

Correct answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

5. The student observes a patient with no breathing problems. Which action by the student indicates a need to review respiratory assessment skills?

• A. The student starts at the apices of the lungs and moves to the bases.
• B. The student compares breath sounds from side to side, avoiding bony areas.
• C. The student places the stethoscope over the posterior chest and listens during expiration.
• D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

Correct answer: C

Rationale: The correct answer is C. Listening only during inspiration instead of both inspiration and expiration indicates a need for a review of respiratory assessment skills. During chest auscultation, it is essential to listen to at least one cycle of inspiration and expiration at each placement of the stethoscope. Instructing the patient to breathe slowly and a little deeper than normal through the mouth is a correct practice during auscultation. The correct sequence for lung auscultation is from the apices to the bases, comparing breath sounds bilaterally, avoiding bony areas. It is crucial to place the stethoscope over lung tissue rather than bony prominences to accurately assess lung sounds.

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