Nursing Elites

1. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

• A. Altered consciousness within the first 24 hours after injury
• B. Confusion immediately following the injury
• C. Headache that resolves quickly
• D. Brief loss of consciousness with a lucid interval

Correct answer: A

Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.

2. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?

• A. Ambulate with a walker for upper body support
• B. Perform abdominal curls to stretch the back muscles
• C. Position in semi-Fowler's with the knees flexed
• D. Encourage straight leg raises while lying supine

Correct answer: C

Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.

3. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

• A. Self-care deficit
• B. Disturbed sleep pattern
• C. Disturbed thought processes
• D. Imbalanced nutrition

Correct answer: D

Rationale: Imbalanced nutrition is the priority in this case as the patient has lost a significant amount of weight and is neglecting self-care, such as bathing and eating properly. The weight loss indicates a serious issue that needs immediate attention to prevent further health complications. While self-care deficit, disturbed sleep pattern, and disturbed thought processes are also concerns for this patient, addressing the imbalanced nutrition takes precedence due to the potential impact on the patient's physical health. Neglecting proper nutrition can lead to serious complications, so it is crucial to address this issue first.

4. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour?

• A. 18
• B. 27
• C. 36
• D. 45

Correct answer: B

Rationale: To calculate the infusion rate, first, find the total dose required per hour, which is the patient's weight (220 pounds) multiplied by the prescribed rate (18 units/kg/hour). This equals 3960 units/hour. Next, determine how many ml of the solution contain 25,000 units; this is 250 ml. Divide the total dose required per hour (3960 units) by the units per ml (25,000 units/250 ml) to find how many ml are needed per hour. This results in 27 ml/hour. Therefore, the nurse should program the infusion pump to deliver 27 ml/hour. Choice A (18) is incorrect as it does not account for the concentration of the heparin solution. Choices C (36) and D (45) are incorrect as they do not reflect the accurate calculations based on the patient's weight and the heparin concentration in the solution.

5. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?

• A. “Yes, I have. Do you have some questions about dying?”
• B. “Several times. Now, let’s get your dressing changed.”
• C. “A few times. It was peaceful and there was no pain.”
• D. “Yes, but you’re doing great. Are you concerned about dying?”

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.

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