Nursing Elites

1. As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?

• A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments.
• B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
• C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments.
• D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.

Correct answer: D

Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.

2. 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.

3. The BRAT diet is often prescribed for patients with gastroenteritis. This acronym stands for:

• A. Bananas, Rice, Applesauce, and Toast
• B. Bread, Rice, Apricots, and Tapioca
• C. Bananas, Rolls, Apricots, and Toast
• D. Bananas, Rolls, Applesauce, and Tapioca

Correct answer: A

Rationale: The BRAT diet, which stands for Bananas, Rice, Applesauce, and Toast, is commonly recommended for patients with gastroenteritis. These easily digestible foods help firm up stools due to their low fiber content and provide essential nutrients lost during vomiting and diarrhea. Choice B is incorrect because it includes apricots, which are not part of the traditional BRAT diet. Choice C is incorrect as it includes rolls, which are not typically included in the BRAT diet. Choice D is incorrect as it includes tapioca, which is not part of the traditional BRAT diet. Therefore, the correct answer is Bananas, Rice, Applesauce, and Toast.

4. While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?

• A. The client is choking on part of the tube
• B. The client has anxiety
• C. The client is having a laryngospasm
• D. The client is having a normal response from anesthesia

Correct answer: D

Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.

5. Albert B. is incontinent of urine. He also wears glasses and hearing aids. His ____________lead(s) to his risk for falls.

• A. incontinence and loss of vision
• B. loss of vision
• C. incontinence
• D. loss of hearing

Correct answer: B

Rationale: Albert B. is at risk for falls due to two factors: his incontinence and his loss of vision. Loss of vision significantly impairs one's ability to navigate and avoid obstacles, thereby increasing the risk of falls. While incontinence is a risk factor for falls, the primary concern in this case is the loss of vision since it directly affects balance and safety. Therefore, the correct answer is 'loss of vision.' Choices A, C, and D are incorrect because they do not address the key factor of impaired vision leading to the risk of falls.

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