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. Which nursing diagnosis is commonly used among patients affected by fibromyalgia?

• A. Decreased self-care in activities of daily living related to fatigue
• B. Impaired mental functioning related to electrolyte imbalances
• C. Increased vigilance secondary to electrolyte imbalances
• D. At risk for a swallowing disorder related to fibromyalgia

Correct answer: A

Rationale: The correct answer is A: 'Decreased self-care in activities of daily living related to fatigue.' Patients with fibromyalgia commonly experience fatigue, which can lead to decreased ability to perform self-care activities. This nursing diagnosis addresses a direct consequence of fibromyalgia. Choices B, C, and D are incorrect because they do not directly correlate with the common manifestations of fibromyalgia. Impaired mental functioning related to electrolyte imbalances and increased vigilance secondary to electrolyte imbalances are not typical presentations of fibromyalgia. 'At risk for a swallowing disorder related to fibromyalgia' is not a common nursing diagnosis associated with fibromyalgia; swallowing disorders are not a primary symptom of this condition.

3. What does the mnemonic device ABCDE stand for?

• A. Allergy, bleeding, chemicals, dietary, environment
• B. Allergy, bleeding, cardio, diabetes, endocrine
• C. Allergy, bleeding, cardio, digestive, endocrine
• D. Allergy, bleeding, cortisone, diabetes, emboli

Correct answer: D

Rationale: The correct answer is D: 'Allergy, bleeding, cortisone, diabetes, emboli.' The ABCDE mnemonic is used in healthcare to help remember key assessment points. Choice A is incorrect as 'chemicals' and 'dietary' are not part of the ABCDE assessment. Choice B is incorrect as 'cardio' is not part of the ABCDE mnemonic. Choice C is incorrect as 'cardio' and 'digestive' are not part of the ABCDE mnemonic.

4. 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.

5. A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take?

• A. Make a copy of the incident report for personal records
• B. Identify the medication name and dosage administered to the client in the report
• C. Obtain an order from the client's provider to complete the report
• D. Include the time the medication error occurred in the report

Correct answer: B

Rationale: The correct answer is to identify the medication name and dosage administered to the client in the incident report. This information is crucial for accurate documentation and investigation of the medication error. Choice A is incorrect because incident reports are usually kept confidential and not for personal keeping. Choice C is incorrect as obtaining an order from the client's provider is not necessary to complete an incident report. Choice D, while important, is not the only essential information needed for the incident report.

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