Nursing Elites

1. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

• A. Paradoxic chest movement
• B. Complaint of chest wall pain
• C. Heart rate of 110 beats/minute
• D. Large bruised area on the chest

Correct answer: A

Rationale: Paradoxic chest movement is the most concerning finding as it indicates a potential flail chest, which can lead to severe compromise in gas exchange and rapid hypoxemia. This condition requires immediate attention to prevent respiratory distress. Complaint of chest wall pain, a slightly elevated heart rate, and a large bruised area on the chest are important assessment findings but may not immediately threaten gas exchange or respiratory function. Therefore, identifying paradoxic chest movement is critical for prompt intervention and management.

2. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?

• A. Induce vomiting
• B. Hold the next dose of Lithium
• C. Administer an antiemetic
• D. Give the next dose of Lithium

Correct answer: B

Rationale: The correct answer is to hold the next dose of Lithium. The blood lithium value of 1.7 mcg/L exceeds the therapeutic range of 0.5-1.5 mcg/L, indicating potential toxicity. Holding the next dose is crucial to prevent further accumulation of lithium in the bloodstream. Inducing vomiting is not appropriate in this situation as the priority is to prevent further absorption of lithium. Administering an antiemetic is not the priority in lithium toxicity. Giving the next dose of lithium would exacerbate the toxicity and should be avoided.

3. A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?

• A. Fear
• B. Helplessness
• C. Self-blame
• D. Rejection

Correct answer: C

Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.

4. The nurse is caring for clients in the pediatric unit. A 6-year-old patient is admitted with 2nd and 3rd degree burns on his arms. The nurse should assign the new patient to which of the following roommates?

• A. A 4-year-old with sickle-cell disease
• B. A 12-year-old with chickenpox
• C. A 6-year-old undergoing chemotherapy
• D. A 7-year-old with a high temperature

Correct answer: A

Rationale: The nurse should be concerned about the burn patient's vulnerability to infection due to compromised skin integrity. Sickle cell disease is not a communicable disease, so rooming the burn patient with a 4-year-old with sickle-cell disease would not pose an increased risk of infection transmission. Rooming the burn patient with a 12-year-old with chickenpox would increase the risk of infection for the burn patient. Rooming with a 6-year-old undergoing chemotherapy may expose the burn patient to potential infections. A 7-year-old with a high temperature could potentially have a contagious illness, which could be risky for the burn patient.

5. A client is admitted for a head injury. His body is lying in an abnormal position and the physician states he is exhibiting decorticate posturing. Based on this assessment, the nurse can expect to find the client with:

• A. The legs extended and rotated internally; the elbow, wrists, and fingers flexed
• B. The legs pulled toward the chest; the head bent back at a 30-degree angle
• C. The back arched; the arms and legs extended and rigid
• D. The legs extended and rotated externally; the head turned to the right or the left

Correct answer: A

Rationale: Decorticate posturing is indicative of an injury to the corticospinal tract, resulting in abnormal posturing. It may occur spontaneously or in response to stimulation. This posture involves the legs being extended and rotated internally, while the elbows, wrists, and fingers are flexed inward. Choice A is correct because it accurately describes the expected positioning associated with decorticate posturing. Choices B, C, and D are incorrect. Choice B describes a different type of posturing known as opisthotonos. Choice C describes an exaggerated arching of the back, which is not characteristic of decorticate posturing. Choice D describes a different type of posturing with external rotation of the legs and head turning to the side, not consistent with decorticate posturing.

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