Nursing Elites

1. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

• A. It is normal among adolescents.
• B. It indicates that the patient has an intact peripheral nervous system.
• C. It indicates that the patient has an intact central nervous system.
• D. It is not a normal finding.

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

2. Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?

• A. The client will be very thirsty.
• B. The client will complain of nausea.
• C. The client will need to urinate.
• D. The client will have moist skin.

Correct answer: D

Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.

3. Which of the following methods of insulin administration would be used in the initial treatment of hyperglycemia in a client with diabetic ketoacidosis?

• A. Subcutaneous
• B. Intramuscular
• C. IV bolus only
• D. IV bolus, followed by continuous infusion

Correct answer: D

Rationale: The correct answer is D: IV bolus, followed by continuous infusion. In the initial treatment of hyperglycemia in a client with diabetic ketoacidosis, insulin is administered via IV bolus to quickly reduce blood glucose levels, followed by a continuous infusion to maintain control. Subcutaneous and intramuscular routes are not used in this situation as they are not rapid or predictable enough to address the acute hyperglycemia seen in diabetic ketoacidosis. IV bolus alone without the continuous infusion may not provide sustained control of blood glucose levels, making choice C incorrect.

4. A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?

• A. Alcoholism
• B. Renal insufficiency
• C. Hypoparathyroidism
• D. Tumor lysis syndrome

Correct answer: A

Rationale: The correct answer is A: Alcoholism. Alcoholism can lead to hypophosphatemia due to poor dietary intake and other factors. Excessive alcohol consumption can result in malnutrition, particularly a deficiency in phosphorus. Choices B, C, and D are unlikely to cause low serum phosphorus levels. Renal insufficiency is more likely to cause hyperphosphatemia, hypoparathyroidism is associated with hypocalcemia rather than hypophosphatemia, and tumor lysis syndrome typically presents with hyperphosphatemia due to the release of intracellular phosphate.

5. Which of the following chronic complications is associated with diabetes?

• A. Dizziness, dyspnea on exertion, and coronary artery disease.
• B. Retinopathy, neuropathy, and coronary artery disease.
• C. Leg ulcers, cerebral ischemic events, and pulmonary infarcts.
• D. Fatigue, nausea, vomiting, muscle weakness, and cardiac arrhythmias.

Correct answer: B

Rationale: The correct answer is B. Diabetes is associated with chronic complications such as retinopathy, neuropathy, and coronary artery disease. Choice A includes symptoms rather than chronic complications of diabetes. Choice C lists conditions not typically associated with diabetes. Choice D describes symptoms that may occur in various medical conditions but are not specific chronic complications of diabetes.

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