Nursing Elites

1. In which of the following examples would informed consent not be required?

• A. A patient is apprehensive about an upcoming surgery and chooses not to learn of the risks involved with the procedure.
• B. A child is rushed to the Emergency Room after falling from a third-story window.
• C. An adult in a coma in a mental health institution with no listed next of kin.
• D. Informed consent is not required in any of the above examples.

Correct answer: D

Rationale: In emergency situations where immediate treatment is necessary to prevent further harm or save a life, such as in option B where a child is rushed to the Emergency Room after a fall, informed consent may be waived to provide prompt care. In option A, though the patient is apprehensive about surgery and chooses not to learn the risks, informed consent is not required as it is the patient's right to refuse information. In option C, when an adult is in a coma with no next of kin listed, decisions may be made in the patient's best interest following legal and ethical guidelines. Therefore, informed consent is not needed in any of the scenarios presented.

2. Your patient has been diagnosed with herpes simplex virus 2. Which of the following would NOT be included in your teaching of this patient?

• A. If you have symptoms, you should avoid sexual contact with other individuals.
• B. With treatment, this condition can be cured.
• C. This disease is highly contagious.
• D. You may experience tingling in the skin before an active outbreak occurs.

Correct answer: B

Rationale: The correct answer is 'With treatment, this condition can be cured.' The treatment for herpes simplex virus (HSV) is symptomatic and palliative, aimed at managing symptoms rather than curing the infection. HSV is highly contagious, so sexual contact should be avoided during active outbreaks to prevent transmission. Many patients experience a tingling sensation in the skin before an active outbreak, known as a prodrome. Educating the patient that the condition is not curable but manageable with treatment is vital to set realistic expectations and promote proper management of the disease.

3. A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.

• A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
• B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
• C. The client should lie flat on their back for a specific period following the procedure.
• D. The risks of the procedure include headache, back pain, and infection.

Correct answer: B

Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.

4. A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:

• A. Malignant hyperthermia
• B. Heat exhaustion
• C. Heat stroke
• D. Heat cramps

Correct answer: B

Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion can lead to heat stroke, which results in organ damage, loss of consciousness, or death.

5. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.

• A. ask for assistance before getting out of bed.
• B. remain in bed because it is safer and he will not fall.
• C. instruct him to stand up quickly from the bed.
• D. lean forward and push up and off the bed.

Correct answer: A

Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.

Similar Questions