Nursing Elites

1. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

2. A home health care nurse is visiting a male African American client who was recently discharged from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications?

• A. The client's grandson
• B. The client's mother
• C. The client's father
• D. The client's son

Correct answer: B

Rationale: In the African American family structure, the woman, especially the mother, often plays a central role in healthcare decisions and maintaining family health. It is essential for the nurse to involve the client's mother in teaching him about his prescribed medications as she may be responsible for his care and treatment decisions. While other family members may also be involved, the African American family is often matrifocal, emphasizing the importance of the mother's role. Therefore, it is crucial for the nurse to ensure the client's mother is present during medication teaching. Choices A, C, and D are incorrect as they do not align with the traditional African American family structure and the role of women in healthcare decisions.

3. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?

• A. Advil
• B. Anasaid
• C. Clinocil
• D. Colace

Correct answer: D

Rationale: The correct answer is Colace. Colace is a stool softener that helps relieve constipation by drawing more water into the bowel, making the stool softer and easier to pass. This is beneficial for an immobilized client as it can help prevent constipation due to decreased mobility. Options A, B, and C (Advil, Anasaid, Clinocil) are not indicated for constipation relief. Advil and Anasaid are nonsteroidal anti-inflammatory drugs used for pain relief, while Clinocil is a fictional medication.

4. Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

• A. refusal to walk
• B. not pulling to a standing position
• C. negative Trendelenburg sign
• D. negative Ortolani sign

Correct answer: B

Rationale: The correct answer is 'not pulling to a standing position.' If an 11-12-month-old child is unable to pull to a standing position, it can indicate a risk for developmental dysplasia of the hip. By 15 months of age, children should be walking, so delayed standing can be a red flag. The Trendelenburg sign is associated with gluteus medius muscle weakness, not hip dysplasia, making choice C incorrect. The Ortolani sign is used to detect congenital hip subluxation or dislocation, not developmental dysplasia, making choice D incorrect.

5. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

• A. Make a referral for grief counseling.
• B. Allow the woman to see her baby initially and respect her wishes for further visits.
• C. Provide opportunities for the woman to express her feelings.
• D. Inform the woman she has the right to change her mind about relinquishment.

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

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