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. Why should direct care providers avoid glued-on artificial nails?

• A. Interfere with dexterity of the fingers.
• B. Could fall off in a patient's bed.
• C. Harbor microorganisms.
• D. Can scratch a patient.

Correct answer: C

Rationale: Direct care providers, including nurses, should avoid glued-on artificial nails because studies have shown that artificial nails, especially when cracked, broken, or split, create crevices where microorganisms can thrive and multiply. This can lead to an increased risk of transmitting infections to patients. Therefore, the primary reason for avoiding glued-on artificial nails is their potential to harbor harmful microorganisms, making option C the correct choice. Options A, B, and D are incorrect because while they may present some issues, the primary concern is the risk of microbial contamination associated with artificial nails.

3. When assessing the force or strength of a pulse, what would the nurse recall about the pulse?

• A. Is a reflection of the heart's stroke volume
• B. Typically recorded on a 0- to 3-point scale
• C. Demonstrates elasticity of the blood vessel wall
• D. Reflects the blood volume in the arteries during diastole

Correct answer: A

Rationale: When assessing the force or strength of a pulse, the nurse should recall that it is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta, causing arterial walls to flare and generate a pressure wave felt as the pulse in the periphery. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not demonstrate the elasticity of blood vessel walls or reflect the blood volume in the arteries during diastole. Therefore, choices B, C, and D are incorrect.

4. 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.

5. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?

• A. Rigor mortis
• B. Postmortem decomposition
• C. Algor mortis
• D. Livor mortis

Correct answer: C

Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.

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