Nursing Elites

1. During an assessment of a male client suspected of having a disorder of motor function, which finding would suggest a possible upper motor neuron (UMN) lesion?

• A. Hypotonia
• B. Hyperreflexia
• C. Muscle atrophy
• D. Fasciculations

Correct answer: B

Rationale: Hyperreflexia, or exaggerated reflexes, is a common sign of an upper motor neuron (UMN) lesion. An UMN lesion indicates damage to the central nervous system pathways that control movement. Hypotonia (choice A) refers to reduced muscle tone, which is more indicative of lower motor neuron lesions. Muscle atrophy (choice C) suggests long-standing denervation or disuse of muscles. Fasciculations (choice D) are involuntary muscle contractions that can be seen in lower motor neuron lesions, like in amyotrophic lateral sclerosis (ALS), rather than UMN lesions.

2. A public health nurse is responsible for the administration of numerous immunizations. Which of the following guidelines regarding anaphylaxis should the nurse adhere to?

• A. The patient should be observed for anaphylaxis for 1 minute after administration.
• B. The patient should be observed for anaphylaxis for 5 minutes after administration.
• C. The patient should be observed for anaphylaxis for 30 minutes after administration.
• D. The patient should be observed for anaphylaxis for 90 minutes after administration.

Correct answer: C

Rationale: The correct answer is C: 'The patient should be observed for anaphylaxis for 30 minutes after administration.' This is because anaphylaxis can occur within minutes of administration of an immunization. By observing the patient for 30 minutes, the nurse can promptly identify and manage any signs of anaphylaxis. Choices A, B, and D are incorrect as they suggest shorter or longer observation periods, which may not be sufficient to detect and respond to anaphylaxis in a timely manner.

3. An infant is being administered an immunization. Which of the following provides an accurate description of an immunization?

• A. It should be administered to a pregnant woman prior to the infant's birth.
• B. It is the administration of an antigen to stimulate an antibody response.
• C. It produces many adverse reactions, particularly autism, in the infant.
• D. It protects the infant from exposure to infectious antibodies.

Correct answer: B

Rationale: The correct answer is B. Immunization involves administering an antigen, such as a weakened or killed microorganism, to stimulate the immune system to produce an antibody response. This process helps the body recognize and remember specific pathogens, providing immunity against future infections. Choice A is incorrect because immunizations are administered to the infant directly, not to the pregnant woman before birth. Choice C is incorrect as there is no scientific evidence linking immunizations to autism. Choice D is incorrect as immunizations protect against infectious agents, not antibodies.

4. What specific instructions should the nurse provide for proper administration of alendronate (Fosamax) in a patient with osteoporosis?

• A. Take the medication with milk to enhance calcium absorption.
• B. Take the medication with a full glass of water and remain upright for at least 30 minutes.
• C. Take the medication at bedtime to ensure absorption during sleep.
• D. Take the medication with food to prevent gastrointestinal upset.

Correct answer: B

Rationale: The correct answer is to take alendronate with a full glass of water and remain upright for at least 30 minutes. This is essential to prevent esophageal irritation and ensure proper drug absorption. Choice A is incorrect as alendronate should not be taken with milk due to potential interactions. Choice C is incorrect as there is no need to take the medication at bedtime specifically. Choice D is incorrect as taking alendronate with food can decrease its absorption.

5. A patient with a history of cardiovascular disease is being prescribed hormone replacement therapy (HRT). What should the nurse include in the patient education regarding the risks associated with HRT?

• A. HRT may increase the risk of cardiovascular events, including heart attack and stroke.
• B. HRT may decrease the risk of osteoporosis.
• C. HRT may increase the risk of venous thromboembolism.
• D. HRT may decrease the risk of breast cancer.

Correct answer: A

Rationale: The correct answer is A. Hormone replacement therapy (HRT) is associated with an increased risk of cardiovascular events, including heart attack and stroke, especially in patients with a history of cardiovascular disease. Choice B is incorrect because HRT does not decrease the risk of osteoporosis; in fact, it may increase the risk of certain conditions like venous thromboembolism, as mentioned in choice C. Choice D is also incorrect as HRT has been associated with a slight increase in the risk of breast cancer.

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