Nursing Elites

1. After experiencing a left frontal lobe CVA, a fifty-five-year-old man is being monitored by a nurse. The patient's family is not present in the room. What should the nurse observe most closely for?

• A. Changes in emotion and behavior
• B. Monitor loss of hearing
• C. Observe appetite and vision deficits
• D. Changes in facial muscle control

Correct answer: A

Rationale: The correct answer is to watch for changes in emotion and behavior. The frontal lobe, particularly the left side, is responsible for regulating behavior and emotions. Therefore, following a left frontal lobe CVA, monitoring for alterations in emotion and behavior is crucial. Choices B, C, and D are incorrect because loss of hearing, appetite and vision deficits, and changes in facial muscle control are not directly associated with a left frontal lobe CVA.

2. The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?

• A. irregular respirations
• B. abdominal respirations
• C. shallow respirations
• D. 70 breaths per minute

Correct answer: D

Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.

3. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing may be potential evidence with legal implications.
• B. Such care facilitates the preservation of potential evidence.
• C. The clothing of a trauma victim can be used for further investigation.
• D. Such care maintains the integrity of the clothing for forensic analysis.

Correct answer: C

Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.

4. Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?

• A. Confusion
• B. Latex Allergy
• C. Acute Pain
• D. Constipation

Correct answer: C

Rationale: Acute Pain is the most appropriate nursing diagnosis for a client experiencing acute pancreatitis because it is a common symptom associated with this condition. Pancreatitis often presents with severe abdominal pain that may radiate to the back. Confusion, Latex Allergy, and Constipation are not typically associated with acute pancreatitis. Confusion may occur in severe cases of pancreatitis with complications, but acute pain is the priority nursing diagnosis due to its prevalence and impact on the client's well-being.

5. After discontinuing a peripherally inserted central line (PICC), what information is most important for the nurse to record?

• A. How the client tolerated the procedure.
• B. The length and intactness of the central line catheter.
• C. The amount of fluid left in the IV solution container.
• D. That a dressing was applied to the insertion site.

Correct answer: B

Rationale: The most important information for the nurse to record after discontinuing a peripherally inserted central line (PICC) is the length and intactness of the central line catheter. This is crucial for assessing any potential complications or safety issues post-removal. Choices A, C, and D are not as critical as ensuring the condition of the central line catheter. While noting the client's tolerance of the procedure is relevant for their care assessment, evaluating the central line's integrity takes precedence in this scenario.

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