Nursing Elites

1. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)

• A. Obtain the pulses in all four extremities
• B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
• C. Determine the client’s orientation to person, place, and time
• D. B, C

Correct answer: D

Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.

2. What causes hepatic encephalopathy?

• A. Buildup of ammonia in the body
• B. Buildup of urea in the body
• C. Fatty infiltration of the liver
• D. Jaundice

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body. Ammonia, a byproduct of protein metabolism, normally gets converted to urea in the liver for excretion. However, in liver dysfunction, such as cirrhosis, the liver cannot effectively convert ammonia to urea, leading to its accumulation in the body and subsequently causing hepatic encephalopathy. Choices B, C, and D are incorrect as they do not directly relate to the pathophysiology of hepatic encephalopathy.

3. Enteral feedings may be appropriate for patients with:

• A. Acute cholecystitis
• B. Hepatic encephalopathy
• C. Ulcerative colitis in remission
• D. Acute exacerbation of Crohn’s disease

Correct answer: D

Rationale: Enteral feedings are commonly utilized for patients experiencing acute exacerbations of Crohn’s disease to provide necessary nutrition and rest the bowel. Choices A, B, and C are incorrect because enteral feedings are not typically indicated for acute cholecystitis, hepatic encephalopathy, or ulcerative colitis in remission.

4. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

• A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
• B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
• C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
• D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress

Correct answer: C

Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.

5. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

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