Nursing Elites

1. The medical record for a client states that the client has hemiplegia. What does this mean?

• A. The client can use his right arm, left leg, and left arm.
• B. The client has paralysis of all four extremities.
• C. The client has decreased vision in one eye.
• D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

2. A nurse is caring for an immobile client. What is the priority assessment in this client?

• A. Auscultation of lung sounds
• B. Assessment of skin turgor
• C. Auscultation of bowel sounds
• D. Assessment for the presence of peripheral edema

Correct answer: A

Rationale:

3. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?

• A. 15 degrees
• B. 0 degrees
• C. 90 degrees
• D. 30 degrees

Correct answer: C

Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.

4. The nurse is caring for 4 clients. Which of these clients will the nurse see first?

• A. A client with sudden and increasing pain in his fractured arm
• B. A client being discharged in 2 hours and needs to be taught how to use his crutches
• C. A client with RA and a scheduled pain medication
• D. A client with a fractured ankle who would like a glass of water

Correct answer: A

Rationale:

5. What evaluation indicates successful progress on the client goal of increasing daily physical activity?

• A. The client reports decreased social interaction
• B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
• C. The client reports a fall
• D. The client reports less fatigue walking up stairs

Correct answer: D

Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.

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