Nursing Elites

1. 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.

2. The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding?

• A. Increase in Forced Vital Capacity (FVC)
• B. A widened chest cavity
• C. Clubbed fingers
• D. An increased risk of cardiac failure

Correct answer: C

Rationale: 1. Increase in Forced Vital Capacity (FVC): Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC. Therefore, this choice is incorrect. 2. A widened chest cavity: A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Hence, a narrowed chest cavity is not an expected finding. 3. Clubbed fingers - CORRECT: Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels, which is commonly seen in patients with chronic respiratory conditions like Emphysema and Chronic Bronchitis. 4. An increased risk of cardiac failure: Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a potential complication and not an assessment finding, making it an incorrect choice.

3. When supporting the psychosocial needs of a client experiencing negative side effects associated with chemotherapy, which intervention is most appropriate?

• A. Read the client's discharge instructions well in advance of dismissal
• B. Provide medications to reduce nausea and vomiting
• C. Give simple instructions about self-care while in the hospital
• D. Determine the levels of support from significant others

Correct answer: D

Rationale: When a client is experiencing negative side effects associated with chemotherapy, addressing their psychosocial needs is crucial. One effective intervention is to determine the levels of support from significant others. This involves assessing the family, spouse, or friends who can provide help and support to the client when healthcare providers are not present. By identifying and organizing these resources, the nurse can help alleviate fears about the future, prepare caregivers for the client's needs, and facilitate a smoother transition for the client upon discharge. Reading discharge instructions, providing medications, or giving self-care instructions, although important, do not directly address the psychosocial needs of the client during this challenging time.

4. Which of the following types of dressing changes works as a form of wound debridement?

• A. Dry dressing
• B. Transparent dressing
• C. Composite dressing
• D. Wet to dry dressing

Correct answer: D

Rationale: The correct answer is 'Wet to dry dressing.' Wet to dry dressing is a method of wound debridement that involves applying sterile soaked gauze to the wound, allowing it to dry and stick to the wound. When the dressing is removed, it pulls away drainage and debris, aiding in wound debridement. Choice A, 'Dry dressing,' does not actively assist in debridement as it does not collect or remove debris from the wound. Choice B, 'Transparent dressing,' is primarily used for maintaining a moist environment and wound observation, not for debridement. Choice C, 'Composite dressing,' combines multiple layers for different wound care purposes but is not specifically designed for debridement like wet to dry dressing.

5. Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?

• A. Weight loss of 2 lb (1 kg)
• B. Positive urine pregnancy test
• C. Hemoglobin level of 10.4 g/dL
• D. Complaints of nausea and anorexia

Correct answer: B

Rationale: A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.

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