Clinical Nursing Fundamental Exam

Correct Answer C: Moist crackles heard upon auscultation

Explanation of the Correct Answer:

Moist Crackles (Lung Sounds)

Crackles (rales) are abnormal lung sounds heard during auscultation, indicating fluid accumulation in the lungs.

This is a common sign of fluid volume excess (FVE), which can lead to pulmonary edema or congestive heart failure.Why the Other Options Are Incorrect:

A: A pinched and drawn facial expression

Incorrect because this is more commonly associated with dehydration (fluid volume deficit) rather than fluid overload.

B: Deep, rapid respirations

Incorrect because deep, rapid respirations (Kussmaul breathing) are more indicative of metabolic acidosis (e.g., diabetic ketoacidosis) rather than fluid volume excess.

D: Tachycardia

Incorrect because while tachycardia can occur in both fluid volume excess and deficit, it is not a definitive indicator of fluid overload.

​​​​​​​In FVE, other symptoms (e.g., hypertension, crackles, edema) are more specific.

Final Summary:

​​​​​​​The presence of moist crackles upon auscultation suggests fluid accumulation in the lungs, making it the best indicator of fluid volume excess. Thus, Option C is the correct answer.

Correct Answer D: It is probable that there are disturbances in self-esteem and body image.

Explanation of the Correct Answer:

The patient has suffered severe burns and cuts on her face, which likely impact her body image due to visible changes in her appearance.

The lack of contact from her fiancé for three weeks may contribute to feelings of rejection, abandonment, and low self-worth, indicating a disturbance in self-esteem.

Her behavior, such as lying with her eyes closed and turning her head away, suggests withdrawal, avoidance, and emotional distress, which are common signs of body image disturbance and low self-esteem.

Her statement about being "too tired" to have visitors may be a defense mechanism to avoid social interactions due to feelings of shame, embarrassment, or emotional pain.

Given these signs, it is highly probable that she is struggling with both self-esteem and body image issues, making this the most appropriate answer.

Explanation of Incorrect Answers:

A: There is no disturbance in self-concept.

Incorrect because the patient is exhibiting multiple signs of emotional distress, including withdrawal and avoidance behaviors.

Major physical trauma, especially facial injuries, frequently affects body image and self-concept.

The absence of a response from her fiancé may further impact her self-worth, making it unlikely that she has no disturbance in self-concept

B: This patient has ego strength and high self-esteem but may have a disturbance of body image.

Incorrect because there is no evidence that she has high self-esteem or strong ego strength.

While a disturbance in body image is likely, her withdrawal, avoidance, and possible emotional distress suggest that her self-esteem is also affected.

​​​​​​​A person with high self-esteem would likely show more adaptive coping mechanisms and not avoid social interactions completely.

C: The area of self-esteem has very low priority at this time and should be ignored until much later.

Incorrect because self-esteem and body image disturbances should be addressed early, even while the patient is still in the recovery phase.

Ignoring emotional distress can lead to depression, anxiety, and poor adjustment to long-term changes in appearance and self-concept.

Holistic nursing care requires addressing both physical recovery and emotional well-being simultaneously.

Summary:

​​​​​​​This patient is likely experiencing both self-esteem and body image disturbances due to her severe facial injuries and lack of contact from her fiancé. Her withdrawal, avoidance behaviors, and reluctance to have visitors indicate emotional distress. Nursing interventions should focus on assessing her emotional well-being, providing psychological support, and promoting a positive self-image early in the recovery process.

Correct Answer C: Unresolved Grief

Why This Answer is Correct

Unresolved grief, also called complicated grief, occurs when a person fails to progress through the normal grieving process and remains emotionally stuck in their loss for an extended period.

In this case, the 82-year-old woman lost her son 20 years ago and still experiences profound distress, an inability to move forward, and a lack of joy in life.

The statement that her life "fell apart" and she "never again felt like herself" suggests that the grief remained unresolved rather than being processed in a healthy way.

This prolonged and intense grief is characteristic of unresolved grief, where a person remains deeply affected by their loss and struggles to adapt to life without their loved one.

Why the Other Options Are Incorrect

Option A:

Somatic Grief

Incorrect because somatic grief refers to physical symptoms (such as headaches, fatigue, stomach pain, or chest pain) that manifest as a response to grief.

This woman describes emotional distress and life dissatisfaction, not physical symptoms.

Option B:

Anticipatory Grief

Incorrect because anticipatory grief occurs before a loss happens, such as grieving for a loved one who has a terminal illness.

​​​​​​​The woman is grieving a loss that already happened 20 years ago, which does not fit the definition of anticipatory grief.

Option D:

Inhibited Grief

Incorrect because inhibited grief occurs when a person suppresses their grief and does not express emotions openly.

People with inhibited grief may deny their loss, avoid talking about it, or refuse to acknowledge their feelings.

​​​​​​​In this case, the woman openly expresses her ongoing distress about her son’s death, so her grief is not inhibited but rather unresolved.

Summary

The correct answer is C. Unresolved Grief, as the woman continues to struggle with deep emotional distress over her son's death, even 20 years later.

​​​​​​​The other options are incorrect because her grief is not somatic (physical symptoms), anticipatory (before the loss), or inhibited (suppressed feelings).

Correct Answer: Neonates and infants (0–6 months old).

Explanation of the Correct Answer:

The CRIES pain scale is a validated neonatal pain assessment tool specifically designed for infants aged 0 to 6 months. It assesses postoperative and procedural pain based on five key behavioral and physiological indicators:

Crying

Required oxygen for saturation above 95%

Increased vital signs (heart rate and blood pressure)

Expression (facial grimacing)

Sleeplessness

Each category is scored from 0 to 2, with a total possible score of 10. A higher score indicates greater pain levels. CRIES is particularly useful in NICU (Neonatal Intensive Care Unit) settings where infants cannot verbally communicate pain.

Explanation of Incorrect Answers:

Option B: Toddlers and preschool-aged children. – Incorrect

Toddlers and young children are typically assessed using the FLACC (Face, Legs, Activity, Cry, Consolability) scale, which is more appropriate for nonverbal children older than six months.

Option C: Adults with cognitive impairment. – Incorrect

Adults with cognitive impairment are often assessed using tools like the PAINAD (Pain Assessment in Advanced Dementia) scale or the Faces Pain Scale-Revised (FPS-R). The CRIES scale is not designed for adult use.

Option D: Postoperative patients of all ages. – Incorrect

While CRIES is designed for postoperative neonatal pain, it is not suitable for children, adolescents, or adults. Other tools like the Numeric Rating Scale (NRS) or Wong-Baker Faces Scale are more appropriate for older patients.

Summary:

The CRIES scale is specifically designed for neonates and infants (0–6 months old) to assess postoperative and procedural pain based on crying, oxygen requirements, vital signs, facial expression, and sleep patterns. It is not appropriate for older children, adults, or cognitively impaired individuals.

Correct Answer: Intercostal muscles

Explanation of the Correct Answer:

The intercostal muscles are located between the ribs and play a crucial role in respiration

There are two main types:

External intercostal muscles: Lift the ribs upward and outward, increasing the thoracic cavity size for inhalation.

Internal intercostal muscles: Help with forced exhalation by pulling the ribs downward.

During inspiration, external intercostal muscle contraction assists in expanding the chest front to back and side to side, allowing air to fill the lungs.

Explanation of Incorrect Answers:

Option A: Diaphragm – Incorrect

The diaphragm is the primary muscle of respiration, but it does not lift the ribs.

Instead, it contracts and moves downward, increasing the vertical space in the thoracic cavity for inhalation.

Option C: Abdominal muscles – Incorrect

Abdominal muscles are mostly involved in forced expiration, where they push the diaphragm upward to help expel air.

They do not lift the ribs or contribute to chest expansion during inhalation.

Option D: Latissimus dorsi – Incorrect

The latissimus dorsi is a large back muscle involved in arm movement and posture, not in respiration.

It does not play a role in lifting the ribs or expanding the chest.

Summary:

​​​​​​​The external intercostal muscles are responsible for lifting the ribs upward and outward, increasing the size of the chest from front to back during inhalation. This helps create negative pressure in the thoracic cavity, allowing air to flow into the lungs.

Correct Answer:

Option a: No action is necessary as this is a normal finding during sleep.

Explanation of the Correct Answer:

Involuntary muscle jerking during sleep is known as a hypnic jerk or sleep myoclonus, which is a normal physiological occurrence.

These jerks most commonly occur during the transition from wakefulness to sleep, specifically in Stage I of non-rapid eye movement (NREM) sleep.

Hypnic jerks are brief and typically do not indicate an underlying medical issue.

Explanation of Incorrect Answers:

Option b: Call the primary care provider to report possible neurologic deficit.

This is incorrect because hypnic jerks are a normal phenomenon and not indicative of a neurological disorder.

A neurological concern would be suspected if the patient had persistent, rhythmic, or seizure-like movements, but occasional myoclonic jerks during sleep are benign.

Option c: Lower the temperature in the patient's room.

There is no evidence that temperature plays a direct role in preventing hypnic jerks.

Although cooler temperatures are generally recommended for sleep, adjusting room temperature would not specifically address this normal physiological occurrence

Option d: Awaken the patient as this is an indication of night terrors.

This is incorrect because night terrors occur in deep NREM sleep (Stage III or IV), not during light sleep when hypnic jerks occur.

Night terrors involve sudden arousals with fear and confusion, but hypnic jerks are brief muscle twitches that do not require waking the patient.

Summary:

Involuntary muscle jerking during sleep is a normal occurrence known as a hypnic jerk. It most commonly happens in the early stages of sleep and does not require medical intervention. The nurse should recognize this as a benign finding and take no further action.

The correct answer is: Wash the radiation site with mild soap.

Explanation for the correct answer:

Wash the radiation site with mild soap: Clients receiving external radiation therapy should be instructed to gently cleanse the treatment area with mild soap and water, pat the area dry, and avoid rubbing. This helps maintain skin integrity and prevents irritation or infection. Proper skin care is essential, as radiation can cause skin reactions such as redness, peeling, or dryness.

Why the other options are wrong:

Apply ice packs to the treatment site to help reduce pain: Incorrect. The application of extreme temperatures, such as ice packs or heating pads, is contraindicated on irradiated skin because it can further damage already sensitive tissue.

Use a sunscreen for three months after the conclusion of the treatments: Incorrect. While protecting the skin from sun exposure is important, clients are advised to avoid sun exposure altogether to the irradiated area for at least 1 year, not just 3 months. Sunscreen alone is not sufficient.

Shave the treated area with a straight razor: Incorrect. Straight razors can cause cuts and trauma to the skin, increasing the risk of irritation and infection in the irradiated area. Clients should be advised to use electric razors or avoid shaving altogether on the treated site.

Summary:

Clients receiving external radiation therapy should be taught to gently wash the area with mild soap, avoid trauma or extreme temperatures, protect the area from sun exposure, and avoid using harsh grooming tools. This helps reduce the risk of skin breakdown and complications during radiation treatment.

Correct Answer : Explore with the patient what, in addition to his family, has given his life meaning and purpose in the past.

Explanation of the Correct Answer:

This intervention focuses on helping the patient reconnect with previous sources of meaning and purpose, which is essential in addressing spiritual distress.

The patient is agnostic, meaning he may not hold traditional religious beliefs. Instead of introducing religious perspectives, it is more effective to explore his personal values, past sources of meaning, and coping mechanisms.

Helping the patient rediscover purpose beyond his loss can support emotional healing and resilience.

Explanation of Incorrect Answers:

Ask the patient which spiritual adviser he would like you to call.

While consulting a spiritual adviser may be helpful for religious patients, this man is a declared agnostic, making it unlikely that he would benefit from this approach.

Recommend that the patient read spiritual biographies or religious books.

​​​​​​​This assumes that religious materials would be meaningful to the patient, but as an agnostic, he may not find them helpful. A more personalized approach would be better.

Introduce the belief that God is a loving and personal God.

This imposes religious beliefs on the patient, which violates patient-centered care principles and may increase distress rather than relieve it.

Summary:

​​​​​​​The best intervention is to help the patient identify past sources of meaning (option c) because it respects his agnostic beliefs while addressing his spiritual distress. The other options assume a religious perspective, which may not align with the patient's worldview.

Correct answer: Obtain a capillary serum glucose level reading with a glucose meter.

Explanation:

The symptoms described (diaphoresis, tachycardia, nervousness, and shakiness) suggest that the client may be experiencing hypoglycemia, a common issue in diabetes management. The first priority is to confirm whether the symptoms are due to low blood sugar. Therefore, obtaining a capillary blood glucose reading using a glucose meter is the most appropriate first action to verify the client’s blood glucose levels before proceeding with further interventions.

Why the other choices are incorrect:

Contact the laboratory and order a serum glucose level:

While this can eventually help determine the glucose level, it is much slower than using a capillary glucose meter. Immediate action is necessary to address potential hypoglycemia, and waiting for lab results could delay treatment.

Provide the patient with a snack of milk and crackers:

If the client is hypoglycemic, providing a quick source of glucose (e.g., a snack with carbohydrates) may be appropriate after confirming the diagnosis. However, it is crucial to first verify the blood glucose level using a glucose meter.

Administer insulin utilizing the prescribed sliding scale dosages:

If the client is hypoglycemic, administering insulin would worsen the condition. Therefore, insulin should not be administered until the blood glucose level has been confirmed and determined to be high.

Summary:

The priority action is to confirm the client's blood glucose level with a capillary glucose meter. This will help determine if the client is experiencing hypoglycemia and guide appropriate treatment.