Nursing Elites

1. What are the key components of a neurological assessment?

• A. Assess level of consciousness and motor function
• B. Check for headache and nausea
• C. Monitor reflexes and pupil size
• D. Assess for tremors and confusion

Correct answer: A

Rationale: The correct answer is A. A neurological assessment includes evaluating the level of consciousness and motor function as they are key components in assessing neurological function. Choices B, C, and D are incorrect as headache, nausea, reflexes, pupil size, tremors, and confusion may be part of a neurological assessment but are not the key components that are fundamental for a comprehensive assessment.

2. During a presentation on basic first aid, a nurse educator evaluates a newly licensed home health nurse's understanding of heat stroke. Which symptom indicates the client has heat stroke?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke can lead to hypotension, which is low blood pressure. This is a common symptom of heat stroke and requires immediate intervention. Bradycardia (slow heart rate), clammy skin, and bradypnea (slow breathing) are not typically associated with heat stroke. In heat stroke, the body's temperature regulation system fails, leading to a rapid rise in body temperature, which can cause various symptoms including hypotension.

3. A nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with food.
• B. I will contact my provider if my heart rate is below 60 beats per minute.
• C. I should take an antacid with this medication to prevent gastrointestinal upset.
• D. I will need to take this medication for 14 days.

Correct answer: B

Rationale: The client should contact their provider if their heart rate drops below 60 beats per minute, as this could indicate digoxin toxicity.

4. What is the primary action the nurse should take first for a client with a pressure ulcer who has a serum albumin level of 3 g/dL?

• A. Increase the protein intake in the diet
• B. Consult with a dietitian to create a high-protein diet
• C. Increase the IV fluid infusion rate
• D. Administer a protein supplement

Correct answer: B

Rationale: The correct answer is to consult with a dietitian to create a high-protein diet. A serum albumin level of 3 g/dL indicates hypoalbuminemia, which can impair wound healing. Consulting with a dietitian to optimize the client's protein intake is crucial in promoting wound healing for pressure ulcers. Increasing the protein intake in the diet (Choice A) may not be sufficient without proper guidance from a dietitian. Increasing the IV fluid infusion rate (Choice C) is not directly related to addressing the protein deficiency. Administering a protein supplement (Choice D) should be guided by a healthcare professional's recommendation after consulting with a dietitian.

5. A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?

• A. Use the cane on the stronger side
• B. Advance the cane and the weaker leg at the same time
• C. Use the cane on the weaker side
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.

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