Nursing Elites

1. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?

• A. Document that the client responds to the painful stimulus.
• B. Observe the client's response to verbal stimulation.
• C. Place the client on seizure precautions for 24 hours.
• D. Report decorticate posturing to the health care provider.

Correct answer: A

Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.

2. Your patient has been confused for years. Your patient can be best described as having a chronic ___________ disorder.

• A. physical
• B. psychotic
• C. thinking
• D. palliative

Correct answer: C

Rationale: Patients who experience long-term confusion often have a chronic thinking, or cognitive, disorder. Alzheimer's disease is a prime example of a disorder that results in prolonged confusion and memory loss. Choice A, 'physical', is incorrect as the issue described is related to cognitive functioning, not physical health. Choice B, 'psychotic', refers to a severe mental disorder characterized by a loss of contact with reality, which is not the primary issue presented in the scenario. Choice D, 'palliative', is not relevant as it pertains to specialized medical care for individuals with serious illnesses, focusing on providing relief from symptoms and stress rather than managing chronic confusion.

3. A client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. Which action would the nurse take?

• A. Evaluate her willingness to pursue adoption.
• B. Encourage her to focus on her own recovery.
• C. Emphasize that she does have two children already.
• D. Ensure that other treatment options for her are explored.

Correct answer: D

Rationale: In this scenario, the nurse should ensure that other treatment options for the client are explored. While a hysterectomy may be necessary for cervical cancer, conservative management options like cervical conization and laser treatment may allow for future pregnancies. It is crucial for the nurse to inform the client of all available treatment choices. Evaluating the client's willingness to pursue adoption is not directly addressing the client's concerns about fertility. Encouraging the client to focus on her own recovery and emphasizing that she already has two children dismiss the client's distress over not being able to have a third child, which is important to acknowledge in a sensitive manner.

4. Which behavior would the nurse recognize as developmentally atypical in preschoolers?

• A. Thumb sucking during stress
• B. Feeling guilty for behaving inappropriately
• C. Feeling happy if there is a newborn in the family
• D. Curiosity about their surroundings

Correct answer: C

Rationale: The correct answer is feeling happy if there is a newborn in the family. Preschoolers are more likely to exhibit feelings of stress and jealousy rather than happiness with the arrival of a new baby in the family. Thumb sucking and bed-wetting are common behaviors displayed by preschoolers during times of stress. Guilt typically arises in children when they perceive that they have not behaved appropriately. Preschoolers are known to be naturally curious about their surroundings, showing an interest in exploring and learning about the environment around them. Therefore, feeling happy with the birth of a new baby is developmentally atypical for preschoolers.

5. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce embolism occurrence.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints, maintaining joint mobility, and preventing stiffness in immobile clients. This intervention helps preserve muscle strength and joint function. Options B, C, and D are incorrect because: Option B suggesting decreasing fluid intake to prevent diarrhea is not relevant to preventing complications of immobility and could lead to dehydration; Option C, massaging the client's legs to reduce embolism occurrence, is not a recommended practice as massage can dislodge blood clots and increase the risk of embolism; Option D, turning the client from side to back every shift, is not sufficient as it does not address the need for maintaining joint mobility and preventing contractures in immobile clients.

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