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 patient receiving isoniazid (INH) and rifampin (Rifadin) has a decreased urinary output and decreased sensation in his great toes. Which laboratory values should be assessed?

• A. Hematocrit and hemoglobin
• B. ALT and AST
• C. Urine culture and sensitivity
• D. Erythrocyte count and differential

Correct answer: C

Rationale: In a patient receiving isoniazid (INH) and rifampin (Rifadin) with symptoms of decreased urinary output and decreased sensation in great toes, assessing urine culture and sensitivity is crucial. These symptoms could indicate peripheral neuropathy, a known side effect of isoniazid, and rifampin can cause renal toxicity. Checking for any urinary tract infection or drug-induced nephrotoxicity is important. Choices A, B, and D are incorrect as they do not directly address the symptoms presented by the patient or the potential side effects of the medications mentioned.

3. A 30-year-old female has suffered a third-degree burn to her hand after spilling hot oil in a kitchen accident. Which teaching point by a member of her care team is most appropriate?

• A. Your hand will likely heal without the need for a skin graft.
• B. You might experience a loss of sensation in your hand after it heals.
• C. Be sure to keep your hand elevated to reduce swelling.
• D. We will need to monitor you for infection as your hand heals.

Correct answer: D

Rationale: In third-degree burns, infection is a major concern due to the extensive damage to the skin. Monitoring for infection is crucial. Choice A is incorrect because third-degree burns often require skin grafts due to the severity of the injury. Choice B is incorrect as loss of sensation is more common in nerve damage and not necessarily in burns. Choice C is incorrect because while elevation can help with swelling in minor burns, it is not the most critical concern in third-degree burns.

4. Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer’s type and confabulates. The nurse understands that this client:

• A. Denies confusion by being jovial.
• B. Pretends to be someone else.
• C. Rationalizes various behaviors.
• D. Fills in memory gaps with fantasy.

Correct answer: D

Rationale: Confabulation, a common symptom in dementia, involves filling in memory gaps with fabricated stories rather than intentionally pretending to be someone else (Choice B), denying confusion by being jovial (Choice A), or rationalizing various behaviors (Choice C). Confabulation is not a deliberate act but a memory error that results in the creation of false memories.

5. What is the primary therapeutic action of tamsulosin (Flomax) in a male patient with benign prostatic hyperplasia (BPH)?

• A. Relaxation of the muscles in the prostate and bladder neck, leading to improved urinary flow.
• B. Reduction in prostate size and improvement in urinary symptoms.
• C. Increase in urine flow and relief of urinary obstruction.
• D. Improvement in erectile function.

Correct answer: A

Rationale: The correct answer is A: Relaxation of the muscles in the prostate and bladder neck, leading to improved urinary flow. Tamsulosin, a medication commonly prescribed for BPH, works by selectively blocking alpha-1 adrenergic receptors in the prostate, causing relaxation of smooth muscles in the prostate and bladder neck. This relaxation reduces the constriction in these areas, improving urinary flow and reducing symptoms such as hesitancy, urgency, frequency, and weak stream. Choice B is incorrect because tamsulosin does not directly reduce the size of the prostate. Choice C is incorrect as tamsulosin primarily acts by relaxing muscles rather than directly increasing urine flow. Choice D is incorrect as tamsulosin is not indicated for improving erectile function.

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