Nursing Elites

1. When assessing a client with amyotrophic lateral sclerosis (ALS), the nurse should expect which of the following findings?

• A. mental confusion
• B. muscular weakness
• C. sensory loss
• D. emotional liability

Correct answer: B

Rationale: Clients with ALS typically present with progressive muscular weakness and wasting as a hallmark feature of the disease. This weakness affects voluntary muscles, leading to challenges in mobility and daily activities. Sensory loss is not a characteristic feature of ALS, and individuals usually maintain their mental clarity without experiencing mental confusion. Emotional liability, characterized by sudden, uncontrolled changes in emotions, is not a common finding in ALS. While individuals may experience periods of grief due to the progressive nature of the disease, emotional liability is not a usual manifestation. Therefore, the correct finding to expect when assessing a client with ALS is muscular weakness.

2. Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?

• A. Impaired Physical Mobility
• B. Dysreflexia
• C. Hypothermia
• D. Impaired Dentition

Correct answer: A

Rationale: As Parkinson's disease progresses and complications develop, impaired physical mobility is a relevant nursing diagnosis due to symptoms like a shuffling gait and rigidity that can impair movement. Dysreflexia is not typically associated with Parkinson's disease; it is more commonly seen in spinal cord injuries. Hypothermia is a condition of low body temperature and is not directly related to Parkinson's disease progression. Impaired Dentition involves issues with teeth and oral health, which are not specific to Parkinson's disease complications.

3. Pulling is easier than pushing. So pulling a client rather than pushing them has which of the following advantages?

• A. reduces workload
• B. decreases opposition from gravity
• C. maintains stability
• D. prevents muscle strain

Correct answer: A

Rationale: When pulling a client, you work with the gravitational force instead of opposing it, which reduces the workload on your muscles. Choosing to pull a client minimizes the effort required compared to pushing. Choice B is incorrect because the force of gravity remains constant regardless of pushing or pulling. Choice C is irrelevant as stability is not directly related to the advantage of pulling over pushing. Choice D is inaccurate because pulling can still strain muscles if not executed correctly, but it generally reduces the overall workload in comparison to pushing.

4. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?

• A. asking whether another individual wants to be her support person
• B. assuring her that a nursing staff member will be with her at all times
• C. telling her you will try to locate her family
• D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control

Correct answer: A

Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (Choice B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (Choice C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (Choice D) is important, it may not fully address her current need for emotional support and presence of a companion.

5. What type of injury is associated with acute hyphema?

• A. orthopedic
• B. eye
• C. insect sting or snakebite
• D. gynecological trauma

Correct answer: B

Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.

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