Nursing Elites

1. A newborn baby exhibits a reflex that includes hand opening, abducted, and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?

• A. ATNR reflex
• B. Startle reflex
• C. Grasping reflex
• D. Moro reflex

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is the correct answer. This reflex is characterized by the baby's response to a sudden head movement or loud noise, causing them to open their hands, extend their arms, and then bring them back towards their body. The characteristics mentioned in the question - hand opening, abducted, and extended extremities following a jarring motion - align with the Moro reflex. The asymmetrical tonic neck reflex (ATNR) involves the head turning to one side with extension of the same side's arm and leg, not the described characteristics. The grasping reflex involves the baby's response to touch on the palm, causing them to grasp an object. While the Moro reflex is often referred to as the startle reflex due to its response to sudden stimuli, the specific characteristics described in the question match the Moro reflex.

2. The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best?

• A. Call the staff nurse in and place them on a work improvement plan after a 3-day suspension
• B. Have the other staff gather additional information on the tardy staff member
• C. Call the staff nurse in for an interview to investigate the problem and possible solutions
• D. Assign a mentor to assist the staff member in arriving on time

Correct answer: C

Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems. Choice A is incorrect as it immediately involves suspension without investigation or support. Choice B is not the best course of action as it does not involve direct communication with the staff member in question. Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.

3. What is the most common cause of acute renal failure?

• A. Shock
• B. Nephrotoxic drugs
• C. Enlarged prostate
• D. Diabetes

Correct answer: A

Rationale: The correct answer is 'Shock.' Acute renal failure is commonly caused by inadequate blood flow to the kidneys, which can occur in cases of shock. This leads to decreased kidney function and potential kidney damage. While nephrotoxic drugs can also cause acute renal failure, shock is the primary and most common cause. An enlarged prostate may lead to obstructive uropathy but is not the most prevalent cause of acute renal failure. Diabetes is typically associated with chronic kidney disease rather than acute renal failure.

4. A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?

• A. Polyphagia
• B. Polyuria
• C. Metabolic acidosis
• D. Lower extremity edema

Correct answer: D

Rationale: Polyphagia, polyuria, and metabolic acidosis are common clinical signs of diabetes mellitus. Polyphagia refers to excessive hunger, polyuria is excessive urination, and metabolic acidosis can occur due to poorly controlled diabetes. Lower extremity edema, on the other hand, is not a typical clinical sign of diabetes mellitus. Edema in the lower extremities is more commonly associated with conditions like heart failure or kidney disease rather than diabetes mellitus.

5. A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).

• A. Weight gain
• B. Fatigue
• C. Bloody sputum
• D. Diaphoresis during sleep

Correct answer: A

Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.

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