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. What should be done immediately after an ankle injury?

• A. Immobilize, heat, compress, and elevate the ankle
• B. Rest, ice, compress, and lower the ankle
• C. Rest, ice, compress, and elevate the ankle
• D. Rest, incubate, confine, and lower the ankle

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.

3. What nursing interventions increase the risk the pressure injuries?

• A. Padding hard surfaces
• B. Have client sit in wheelchair as much as possible
• C. Place pillows between bony surfaces
• D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

4. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

• A. Exophthalmos
• B. Anisocoria
• C. Strabismus
• D. Scleral edema

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

5. What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not?

• A. The client with AIDS is a susceptible host
• B. The client with AIDS has greater immune defenses
• C. The client with AIDS was not as careful
• D. The client with AIDS has more portals of entry

Correct answer: A

Rationale:

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