Nursing Elites

1. A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

• A. File an incident report.
• B. Ask the client about his injuries with the son present.
• C. Ask the client's son to go to the waiting area.
• D. Treat and discharge the client

Correct answer: C

Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.

2. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

• A. It is normal among adolescents.
• B. It indicates that the patient has an intact peripheral nervous system.
• C. It indicates that the patient has an intact central nervous system.
• D. It is not a normal finding.

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

3. Select all of the risk factors that are associated with deep vein thrombosis.

• A. The use of oral contraceptives
• B. Type B and O blood
• C. Rh negative blood
• D. Underweight

Correct answer: A

Rationale: The correct answer is A: "The use of oral contraceptives." Risk factors for deep vein thrombosis include factors such as immobility, surgery, cancer, obesity, smoking, and the use of oral contraceptives. Choices B, C, and D are incorrect because blood type and Rh factor do not play a role in the development of deep vein thrombosis, and being underweight is not typically considered a risk factor for this condition.

4. Which of the following new opportunities might a new nurse see in the future?

• A. Transitional care
• B. Traditional care
• C. Hospital-based care
• D. Care based on cost

Correct answer: A

Rationale: In the future, new nurses may see opportunities in transitional care. Transitional care involves the coordination and continuity of healthcare during a movement from one healthcare setting to another. This type of care is increasingly important in today's healthcare landscape due to the focus on improving patient outcomes and reducing hospital readmissions. Choices B, C, and D are incorrect as they do not represent emerging opportunities for new nurses in the future. Traditional care and hospital-based care are existing models of care delivery, while care based solely on cost does not align with the holistic approach to patient care that is becoming more prevalent in healthcare.

5. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

• A. Transport the client to the operating room without verifying informed consent
• B. Ask the anesthesiologist to sign the consent
• C. Obtain telephone consent from the facility administrator before the surgery
• D. Delay the surgery until the nurse can obtain informed consent

Correct answer: A

Rationale: In emergency situations where a client is unconscious and requires immediate surgery, implied consent applies. Implied consent allows healthcare providers, including nurses, to proceed with necessary treatment or surgery without formally verifying informed consent. Choice A is correct because the priority in this scenario is to ensure the client receives timely medical intervention to address life-threatening conditions. Choices B, C, and D are incorrect because in emergencies, waiting to obtain formal consent can delay critical treatment, risking the client's health and well-being.

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