Nursing Elites

1. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glascow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glascow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.

2. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

• A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
• B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
• C. The arms should be crossed over the chest or in the lap.
• D. The feet should be close together with toes pointed out.

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

3. Which toy is most appropriate for an 18-month-old child?

• A. A pull toy
• B. A puzzle with large pieces
• C. A book with large pictures
• D. A doll with small clothes

Correct answer: A

Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.

4. A healthcare professional is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the healthcare professional use first?

• A. Inspection
• B. Palpation
• C. Auscultation
• D. Percussion

Correct answer: A

Rationale: Inspection is the initial step in abdominal assessment as it allows the healthcare professional to visually observe any abnormalities or signs of bloating. Palpation, auscultation, and percussion are subsequent assessment techniques that follow inspection. Palpation involves feeling for tenderness, masses, or organ enlargement; auscultation is listening for bowel sounds; and percussion is used to assess the density of underlying tissues or detect the presence of fluid or air in the abdomen. In the context of a client reporting bloating, the first step should be visual inspection to gather initial information. Palpation, auscultation, and percussion come after inspection to provide a more comprehensive assessment.

5. During an initial history and physical assessment of a 3-month-old brought into the clinic for spitting up and excessive gas, what would the nurse expect to find?

• A. Increased temperature and lethargy
• B. Restlessness and increased mucus production
• C. Increased sleeping and listlessness
• D. Diarrhea and poor skin turgor

Correct answer: B

Rationale: Restlessness and increased mucus production are common signs of gastrointestinal issues or reflux in infants, which could explain the symptoms of spitting up and excessive gas. Increased temperature and lethargy (Choice A) are more indicative of an infection rather than gastrointestinal issues. Increased sleeping and listlessness (Choice C) are not typical signs associated with the symptoms described. Diarrhea and poor skin turgor (Choice D) are not directly related to the symptoms of spitting up and gas in this scenario.

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