Nursing Elites

1. A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?

• A. Administer glucosamine supplements
• B. Turn the client every 2 hours
• C. Provide active range of motion (ROM)
• D. Provide passive range of motion (ROM)

Correct answer: D

Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.

2. To promote independence, which of these is the best intervention to implement?

• A. Perform the client’s activities of daily living for them.
• B. Speak directly in front of the client so they can read your lips well.
• C. Give the client their washcloth and toothbrush and leave the room.
• D. Allow the client to perform the activities of daily living they are able to do.

Correct answer: D

Rationale: The correct answer is to allow the client to perform the activities of daily living they are able to do. This intervention promotes independence by encouraging clients to maintain their functional abilities. Choice A is incorrect as performing the client's activities of daily living for them does not empower independence. Choice B is irrelevant to promoting independence. Choice C is not actively promoting independence as it involves leaving the client alone without any guidance or support.

3. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

• A. Two-point gait
• B. Three-point gait
• C. Four-point gait
• D. Unaffected gait

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

4. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?

• A. I am sorry you did not understand. Would you like a different doctor?
• B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
• C. You will need to have glasses.
• D. This means you won’t ever need glasses.

Correct answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.

5. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?

• A. Amputation
• B. Deep vein thrombosis
• C. Internal bleeding
• D. Kidney failure

Correct answer: B

Rationale:

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