Nursing Elites

1. During which stage of anesthesia is a patient most likely to experience involuntary motor activity?

• A. Stage I
• B. Stage II
• C. Stage III
• D. Stage VI

Correct answer: B

Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements. Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur. Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage. Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.

2. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician, and the physician prescribes dietary instructions based on the sodium level. Which food item should the nurse instruct the client to avoid?

• A. Peas
• B. Cauliflower
• C. Low-fat yogurt
• D. Processed oat cereals

Correct answer: D

Rationale: The correct answer is processed oat cereals. Processed oat cereals are often high in sodium content, which should be avoided in cases of hypernatremia. Peas, cauliflower, and low-fat yogurt are generally low in sodium and are not typically contraindicated in hypernatremia. Therefore, choices A, B, and C are incorrect.

3. A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?

• A. A client who has an open fracture of the femur
• B. A client who has periorbital ecchymosis
• C. A client who has asymmetrical thorax
• D. A client who has a deep-partial thickness burn on the lower extremities

Correct answer: C

Rationale: In a triage situation, an asymmetrical thorax suggests a potentially life-threatening condition such as a pneumothorax or hemothorax, requiring immediate attention. This client should be tagged as emergent. Periorbital ecchymosis and deep-partial thickness burns, while concerning, may not indicate an immediate life-threatening situation. An open fracture of the femur, although serious, can be prioritized after addressing emergent cases.

4. A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

• A. I hope I can adjust to using crutches while I am recovering.
• B. I am worried about taking care of my toddler at home.
• C. I just don't think I can handle looking at my leg.
• D. I am not sure how I will pay for all the therapy I will need.

Correct answer: A

Rationale: The client's statement about adjusting to using crutches while recovering suggests a potential need for occupational therapy referral. Occupational therapists assist individuals in regaining independence in activities of daily living, including mobility aids and adaptations. Choices B, C, and D are more indicative of emotional or financial concerns and may require referrals to other healthcare professionals like counselors or financial advisors, rather than occupational therapists.

5. A case manager is preparing a discharge plan for a client following coronary artery bypass grafting surgery. Which of the following client issues should the nurse address first?

• A. Inadequate food supply
• B. Low pain tolerance
• C. Limited social support
• D. Decreased self-esteem

Correct answer: A

Rationale: The nurse should address the inadequate food supply first as it directly impacts the client's health post-discharge. Proper nutrition is crucial for recovery after surgery, especially such as coronary artery bypass grafting. While low pain tolerance, limited social support, and decreased self-esteem are all important issues to address, addressing the client's nutritional needs is the priority in this scenario to ensure optimal recovery and healing.

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