Nursing Elites

1. An older adult patient brought to the emergency department by a family member is wandering outside, saying, "I can't find my way home."? The patient is confused and unable to answer questions. What is the nurse's best action?

• A. Document the patient's mental status and obtain other assessment data from the family member.
• B. Record the patient's answers to questions on the nursing assessment form.
• C. Ask an advanced practice nurse to perform the assessment interview.
• D. Call for a mental health advocate to maintain the patient's rights.

Correct answer: A

Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.

2. Which of the following statements best describes footdrop?

• A. The foot is permanently fixed in the dorsiflexion position
• B. The foot is permanently fixed in the plantar flexion position
• C. The toes of the foot are permanently fanned
• D. The heel of the foot is permanently rotated outward

Correct answer: B

Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.

3. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

• A. Help the client to get settled and conduct the interview the next morning when the client is rested
• B. Conduct the interview immediately, directing the majority of the questions to the client
• C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
• D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

Correct answer: C

Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.

4. A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?

• A. 142/92
• B. 118/72
• C. 120/80
• D. 138/88

Correct answer: A

Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.

5. During a class on the aspects of culture, the instructor shares that culture has four basic characteristics. Which statement correctly reflects one of the characteristics of culture?

• A. Static and unchanging
• B. Members sharing similar physical characteristics
• C. Members sharing a common geographic origin and religion
• D. Adapted to specific conditions related to environmental and technical factors

Correct answer: D

Rationale: Culture has four basic characteristics, one of which is that it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. The other three characteristics are: (1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the cultural group; and (3) dynamic and ever-changing. Culture is not static and unchanging but is dynamic and ever-changing. Members of a culture do not necessarily share similar physical characteristics; that refers to race. Similarly, members of a culture do not necessarily share a common geographic origin and religion; that refers to ethnicity.

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