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. A newborn infant in the nursery has developed vomiting, poor feeding, lethargy, and respiratory distress, and has been diagnosed with necrotizing enterocolitis. Which of the following nursing interventions is most appropriate for this infant?

• A. Feed the infant 30 cc of sterile water
• B. Position the infant on his back
• C. Administer antibiotics as ordered
• D. Allow the infant to breastfeed

Correct answer: C

Rationale: Necrotizing enterocolitis (NEC) is a serious condition characterized by ischemic bowel, leading to gastrointestinal symptoms, lethargy, poor feeding, and respiratory distress. In the management of NEC, it is crucial to stop oral feedings, insert a nasogastric tube for decompression, and administer antibiotics as prescribed by the physician. Therefore, the most appropriate nursing intervention for an infant with NEC is to administer antibiotics as ordered. Choice A, feeding the infant sterile water, is incorrect because oral feedings should be stopped in NEC. Choice B, positioning the infant on his back, is not directly related to the treatment of NEC. Choice D, allowing the infant to breastfeed, is contraindicated in NEC as oral feedings should be ceased to prevent further complications.

3. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:

• A. Instruct the client to maintain a regular diet the day prior to the examination.
• B. Restrict the client's fluid intake 4 hours prior to the examination.
• C. Administer a laxative to the client the evening before the examination.
• D. Inform the client that only 1 x-ray of his abdomen is necessary.

Correct answer: C

Rationale: The correct preparation for an Intravenous Pyelogram (IVP) involves administering a laxative to the client the evening before the examination. This is crucial to ensure adequate bowel preparation, which in turn allows for better visualization of the bladder and ureters during the procedure. An IVP is an x-ray exam that utilizes contrast material to evaluate the kidneys, ureters, and bladder, aiding in the diagnosis of conditions like blood in the urine or pain in the side or lower back. Administering a laxative helps in achieving optimal imaging quality, which is essential for accurate diagnosis and subsequent treatment planning. Choice A is incorrect because maintaining a regular diet is not the standard preparation for an IVP. Choice B is incorrect as fluid intake is not typically restricted for this procedure. Choice D is incorrect as an IVP involves multiple x-rays to assess the urinary system, not just one of the abdomen.

4. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?

• A. Drink small amounts of liquids frequently
• B. Eat the evening meal at least 2-3 hours before bedtime
• C. Take sodium bicarbonate after each meal
• D. Sleep with head propped on several pillows

Correct answer: D

Rationale: During the third trimester, many women experience heartburn due to the pressure of the growing uterus on the stomach. Elevating the head while sleeping can help prevent gastric contents from refluxing back into the esophagus, thus reducing heartburn symptoms. Drinking small amounts of liquids frequently may exacerbate heartburn by increasing stomach distension. Eating the evening meal just before retiring can also worsen heartburn symptoms as lying down shortly after eating can promote reflux. Taking sodium bicarbonate after each meal is not recommended as it can disrupt the body's natural pH balance and lead to other complications.

5. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

• A. Rice
• B. Oatmeal
• C. Rye toast
• D. White bread

Correct answer: A

Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats. Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.

Similar Questions