Nursing Elites

1. In the ICU setting, a client transported from surgery following open heart bypass grafting will likely have his or her core temperature measured by:

• A. oral thermometer.
• B. rectal thermometer.
• C. esophageal thermometer.
• D. temporal artery thermometer.

Correct answer: C

Rationale: An esophageal thermometer is commonly used in ICU settings to accurately measure core body temperature, especially in post-surgical patients. The esophageal thermometer provides a more precise measurement of core temperature compared to other methods like oral, rectal, or temporal artery thermometers. In the ICU, accuracy in temperature measurement is crucial for detecting and responding to changes promptly, making the esophageal thermometer the preferred choice in this scenario.

2. Not realizing that its surface was hot, a woman has quickly withdrawn her hand from the surface of a bowl that she was removing from a microwave. Which phenomena has facilitated the rapid movement of her hand in response to the painful stimulus?

• A. Crossed-extensor reflex
• B. Flexor reflex
• C. Withdrawal reflex
• D. Stretch reflex

Correct answer: C

Rationale: The withdrawal reflex is a protective response that allows a person to quickly remove their hand from a painful stimulus.

3. Which of the following describes the type of incontinence due to an increase in intraabdominal pressure such as coughing, sneezing, and laughing?

• A. Overflow
• B. Stress
• C. Mixed
• D. Functional

Correct answer: B

Rationale: The correct answer is B: Stress. Stress incontinence occurs when there is an increase in intraabdominal pressure, for example, during activities like coughing, sneezing, or laughing, leading to urine leakage. This type of incontinence is specifically triggered by physical movements or activities that put pressure on the bladder. Choices A, C, and D are incorrect because overflow incontinence is characterized by the bladder not emptying properly, mixed incontinence is a combination of stress and urge incontinence, and functional incontinence is typically due to physical or cognitive impairments.

4. Which statement best conveys an aspect of the role of cerebrospinal fluid (CSF)?

• A. CSF provides immune protection to the brain and spinal cord by serving as a physical barrier.
• B. CSF cushions the brain and spinal cord, protecting them from injury.
• C. CSF plays a limited role in the exchange of nutrients and waste products between the blood and brain.
• D. CSF functions primarily as a medium for the transmission of nerve impulses.

Correct answer: B

Rationale: The correct answer is B. Cerebrospinal fluid primarily cushions the brain and spinal cord, protecting them from injury. Choice A is incorrect because while CSF contributes to the brain's immune environment, its main role is not providing immune protection as a physical barrier. Choice C is incorrect because CSF has a significant role in the exchange of nutrients and waste products, rather than a limited one. Choice D is incorrect as CSF is not primarily a medium for nerve impulse transmission, but rather serves as a protective and supportive fluid.

5. A 50-year-old female was diagnosed with sideroblastic anemia. Which of the following assessment findings would most likely occur?

• A. Bronze-colored skin
• B. Decreased iron
• C. Normochromic erythrocytes
• D. Aplastic bone marrow

Correct answer: A

Rationale: The correct answer is A: 'Bronze-colored skin.' Sideroblastic anemia is characterized by excess iron deposition, leading to bronze-colored skin. This occurs due to the abnormal accumulation of iron in tissues. Choices B, C, and D are incorrect because sideroblastic anemia does not typically present with decreased iron levels, normochromic erythrocytes, or aplastic bone marrow.

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