Nursing Elites

1. A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?

• A. Variable decelerations
• B. Late decelerations
• C. Early decelerations
• D. Accelerations

Correct answer: B

Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (Choice A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (Choice C) are usually benign and mirror the contraction pattern. Accelerations (Choice D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.

2. Which of the following screening tools have been found to have high diagnostic accuracy for screening for intimate partner violence?

• A. Hurt, Insult, Threaten, and Scream (HITS)
• B. Humiliation, Afraid, Rape, and Kick (HARK)
• C. Slapped, Threatened, and Thrown (STaT)
• D. All of the above

Correct answer: D

Rationale: All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.

3. A client needs to give informed consent for electroconvulsive therapy treatments. Which of the following actions should the nurse take?

• A. Explain the adverse effects the client might experience from the treatment
• B. Verify the client gave consent voluntarily for the treatment
• C. Describe the benefits of the treatment to the client
• D. Outline possible alternatives to the treatment for the client

Correct answer: B

Rationale: When obtaining informed consent for a procedure like electroconvulsive therapy, the nurse's primary responsibility is to ensure that the client has given consent voluntarily and is capable of making such a decision. While it is essential to provide information on the treatment's benefits, risks, and alternatives, the priority is to verify the client's voluntary consent. Explaining the adverse effects and describing the benefits are important steps in the informed consent process, but the critical step is to confirm the client's voluntary agreement. Outlining possible alternatives to the treatment is also important but comes after ensuring the client's voluntary consent.

4. The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?

• A. Irregular breathing patterns
• B. Minimal heartbeat, dilated pupils
• C. Relaxed muscles, regular breathing, constricted pupils
• D. Euphoria, drowsiness, dizziness

Correct answer: D

Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.

5. The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?

• A. Let them talk to another patient who has had the same therapy
• B. Provide research-based information about therapeutic hypothermia
• C. Connect them with the nurse manager
• D. Call the physician and ask him to talk to the family

Correct answer: B

Rationale: Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.

Similar Questions