Nursing Elites

1. A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

• A. The client is observed shaving only one side of his face.
• B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
• C. The client is unable to complete a range of vision without turning his head side to side.
• D. The client is unable to carry out cognitive and motor activity at the same time.

Correct answer: A

Rationale: Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body. Choices B, C, and D are not associated with unilateral neglect. Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body. Choice C describes a visual field cut, which is a different visual deficit. Choice D relates to dual-task interference, not specific to ignoring one side of the body.

2. The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time?

• A. Warm the room
• B. Submerge the hand in warm water
• C. Order a K pad and apply to hand
• D. Have the client exercise the fingers to increase blood flow

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a burn victim with a skin graft to the hand, exhibiting pale and mottled skin but good capillary refill, is to warm the room. By warming the room, the nurse helps promote circulation and maintain a conducive environment for healing. Submerging the hand in warm water can pose a risk of injury or infection to the graft site. Ordering a K pad and applying it to the hand may not be necessary at this time and could potentially cause harm. Having the client exercise the fingers to increase blood flow is also not recommended as it may interfere with the healing process of the skin graft.

3. A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?

• A. Transferring the patient to the shower.
• B. Ambulating the patient for the first time.
• C. Taking the patient's breath sounds.
• D. Educating the patient on monitoring fatigue.

Correct answer: A

Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.

4. In alcoholics with anemia:

• A. Pernicious anemia is more common than folic acid deficiency.
• B. Iron deficiency and folic acid deficiency can coexist.
• C. The alcohol interferes with iron absorption.
• D. Oral vitamin replacement is contraindicated.

Correct answer: B

Rationale: In alcoholics with anemia, iron deficiency and folic acid deficiency can coexist due to poor dietary intake and malabsorption issues associated with chronic alcohol consumption. Pernicious anemia, primarily related to vitamin B12 deficiency, is not commonly seen in alcoholics. While alcohol can interfere with iron absorption, it is not the sole factor contributing to anemia in alcoholics. Oral vitamin replacement is not contraindicated in alcoholics with anemia; however, it may be less effective due to absorption issues related to alcohol consumption.

5. The physician wants to know if a client is tolerating their total parenteral nutrition. Which of the following laboratory tests is likely to be ordered?

• A. triglyceride level
• B. liver function tests
• C. a glucose tolerance test
• D. a complete blood count

Correct answer: B

Rationale: The liver is crucial in processing nutrients and medications received through total parenteral nutrition. Liver function tests assess various enzymes produced by the liver, including prothrombin time/partial prothrombin time, serum glutamic oxaloacetic and pyruvic transaminases, gamma glutamyl transpeptidase, albumin, and alkaline phosphatase. Monitoring these enzymes can help determine if the liver is functioning properly to metabolize the nutrients from TPN. Triglyceride levels (Choice A) primarily evaluate the body's ability to clear fats, not specifically related to TPN tolerance. A glucose tolerance test (Choice C) is used to diagnose diabetes by measuring blood glucose levels after ingesting a glucose-rich solution, not directly related to TPN tolerance. A complete blood count (Choice D) assesses blood components such as red blood cells, white blood cells, and platelets but does not provide specific information about TPN tolerance.

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