Nursing Elites

1. Mobility is an important human function. The hazards of immobility lead to many physical and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin, and emotional changes. Which of the following is an example of a skeletal hazard of immobility?

• A. Contractures.
• B. Constipation.
• C. Calcium loss.
• D. Catabolism.

Correct answer: C

Rationale: All choices are hazards of immobility, but only calcium loss from the bones is a skeletal system impairment that results from immobility. Contractures are muscle shortening due to prolonged positioning, which affects the muscular system. Constipation is a gastrointestinal issue. Catabolism is a metabolic process, not specific to the skeletal system.

2. 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.

3. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

• A. The adolescent gives away a DVD player and a cherished autographed picture of a performer.
• B. The adolescent runs out of group therapy, swearing at the group leader, and then goes to her room.
• C. The adolescent becomes angry while speaking on the phone and slams down the receiver.
• D. The adolescent gets angry with her roommate when the roommate borrows her clothes without asking.

Correct answer: A

Rationale: The correct answer is when the adolescent gives away a DVD player and a cherished autographed picture of a performer. This behavior is concerning because a depressed suicidal client often gives away things of value as a way of saying goodbye and wanting to be remembered. Choices B, C, and D all involve anger and acting-out behaviors, which are common in adolescents but do not specifically indicate suicidal ideation. Running out of group therapy, swearing, and going to her room, becoming angry and slamming the phone receiver, or getting upset when her roommate borrows her clothes are not clear indications of suicidal thoughts.

4. A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

• A. G4 T1 P0 A1 L2
• B. G3 T1 P0 A1 L2
• C. G3 T0 P1 A1 L2
• D. G4 T0 P1 A1 L2

Correct answer: D

Rationale: The correct answer is G4 T1 P0 A1 L2. This documentation accurately represents the woman's obstetric history. G4: She is currently pregnant (1), has twins (1), and had a miscarriage (1), totaling four pregnancies. T1: She has had one pregnancy that resulted in the birth of her twins at term. P0: She has not had any preterm births. A1: She had one miscarriage at 12 weeks gestation. L2: She has two living children (the twins). Therefore, the correct documentation reflects all aspects of her obstetric history as provided.

5. Which of the following tasks may be delegated to unlicensed assistive personnel?

• A. Cleansing a wound with peroxide
• B. Irrigating a colostomy
• C. Assisting with performing incentive spirometry
• D. Removing a saline-lock IV

Correct answer: C

Rationale: Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (Choice A) and irrigating a colostomy (Choice B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (Choice D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.

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