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. A nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?

• A. Restrict the client's fluid intake.
• B. Monitor the client's deep-tendon reflexes.
• C. Place the client in the lithotomy position.
• D. Encourage the client to ambulate frequently.

Correct answer: B

Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.

3. A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.

4. A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.

5. A nurse is providing discharge instructions to a client with home oxygen therapy. Which of the following is essential for safety?

• A. Allow the client to smoke in designated outdoor areas
• B. Place the oxygen equipment 10 feet away from any open flames
• C. Keep oxygen tanks upright at all times
• D. Restrict fluid intake while using oxygen

Correct answer: C

Rationale: The correct answer is to keep oxygen tanks upright at all times. This is essential for safety as it prevents the tanks from falling and causing injury. Allowing the client to smoke in designated outdoor areas (Choice A) is unsafe as smoking near oxygen equipment can lead to a fire. Placing the oxygen equipment 10 feet away from any open flames (Choice B) is important to prevent fire hazards, but keeping the tanks upright is more directly related to preventing injuries. Restricting fluid intake while using oxygen (Choice D) is not necessary for safety in home oxygen therapy.

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