Nursing Elites

1. What type of injury is associated with acute hyphema?

• A. orthopedic
• B. eye
• C. insect sting or snakebite
• D. gynecological trauma

Correct answer: B

Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.

2. When are pressure ulcers most likely to occur?

• A. when clients are left in one position in bed for extended periods of time.
• B. when clients are underweight.
• C. when clients are overweight.
• D. only in underweight and overweight clients.

Correct answer: A

Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client. Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.

3. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?

• A. asking whether another individual wants to be her support person
• B. assuring her that a nursing staff member will be with her at all times
• C. telling her you will try to locate her family
• D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control

Correct answer: A

Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (Choice B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (Choice C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (Choice D) is important, it may not fully address her current need for emotional support and presence of a companion.

4. A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?

• A. Heart rate
• B. Peripheral pulses
• C. Blood pressure (BP)
• D. Radial pulse rate

Correct answer: B

Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.

5. What should be included in the assessment of a client with a cast?

• A. capillary refill, warm toes, no discomfort.
• B. posterior tibial pulses, warm toes.
• C. moist skin essential, pain threshold.
• D. discomfort of the metacarpals.

Correct answer: A

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.

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