Nursing Elites

1. Which of the following signs or symptoms indicates a possible nutritional deficiency?

• A. Subcutaneous fat at the waist and abdomen
• B. Presence of papillae on the surface of the tongue
• C. Straight arms and legs
• D. Pale conjunctiva

Correct answer: D

Rationale: A client with poor nutritional intake may have pale mucous membranes surrounding the eye, or the conjunctiva. This area should normally be pink, indicating good circulation and a lack of irritation or dryness. Improper nutrition can manifest as numerous signs in the body, including bowed legs, pale mucous membranes, a smooth or beefy tongue, and poor muscle tone. Subcutaneous fat at the waist and abdomen is not a sign of nutritional deficiency but rather of excess fat deposition. The presence of papillae on the surface of the tongue is normal and not indicative of a nutritional deficiency. Straight arms and legs are also typical anatomical features and not specifically related to nutritional deficiencies.

2. An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed?

• A. Rotating the lens selector dial to bring the object into focus
• B. Using the large full circle of light when assessing pupils that are not dilated
• C. Rotating the lens selector dial to the black numbers to compensate for astigmatism
• D. Using the grid on the lens aperture dial to visualize the external structures of the eye

Correct answer: A

Rationale: To correctly perform an eye examination using an ophthalmoscope on a patient with astigmatism and nearsightedness, the examiner should rotate the lens selector dial to bring the object into focus. This adjustment helps compensate for nearsightedness or farsightedness but does not correct astigmatism. Rotating the lens selector dial to the black numbers is not an appropriate technique for compensating for astigmatism. Using the grid on the lens aperture dial is primarily for visualizing external structures of the eye, not for addressing refractive errors. The large full circle of light is typically used when assessing dilated pupils, not for examining patients with astigmatism and nearsightedness. Therefore, the correct technique is rotating the lens selector dial to bring the object into focus.

3. When teaching a patient to use the three-point gait technique of crutch use:

• A. The injured leg moves ahead at the same time as both crutches.
• B. One crutch moves at a time and is then followed by the injured leg.
• C. Both crutches move ahead at the same time followed by both legs at the same time.
• D. None of the above are correct.

Correct answer: A

Rationale: The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.

4. 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.

5. A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?

• A. Anorexia
• B. Aspiration
• C. Self-care deficit
• D. Inadequate intake

Correct answer: B

Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (Choice A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (Choice C) and inadequate intake (Choice D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.

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