Nursing Elites

1. A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?

• A. "Given time and motivation, your son may regain some function, but I will seek more information from the physician."?
• B. Maintain a calm demeanor and speech pattern while addressing the mother's concerns.
• C. "I'm not sure, but I'll call the physician to discuss this with you promptly."?
• D. "It's not beneficial for your son if you get upset."?

Correct answer: C

Rationale: The best initial response in this situation is to acknowledge the mother's concern, express uncertainty, and offer to obtain more information from the physician. By saying, "I'm not sure, but I'll call the physician to discuss this with you promptly,"? the nurse demonstrates empathy, honesty, and a commitment to providing accurate information. Offering vague reassurance (Choice A) may raise false hopes as outcomes for spinal cord injuries are unpredictable. While maintaining a calm demeanor (Choice B) is important, it does not directly address the mother's immediate need for information. Discouraging the mother from feeling upset (Choice D) is dismissive of her emotions and does not address her question, which is seeking information about her son's prognosis.

2. Signs of impaired breathing in infants and children include all of the following except:

• A. nasal flaring
• B. grunting
• C. seesaw breathing
• D. quivering lips

Correct answer: D

Rationale: Signs of impaired breathing in infants and children typically include nasal flaring, grunting, and seesaw breathing. Nasal flaring is the widening of the nostrils during breathing to help with air intake, grunting is a sound made during expiration to keep the airway open, and seesaw breathing is an abnormal pattern where the chest moves in while the abdomen moves out. Quivering lips are not a typical sign of impaired breathing in infants and children, making it the correct answer. Nasal flaring, grunting, and seesaw breathing are all signs indicating the need for immediate medical attention due to potential respiratory distress.

3. What is the number one reason a person with alcohol addiction does not seek treatment?

• A. Co-dependency
• B. Denial
• C. Depression
• D. Stigma

Correct answer: B

Rationale: The correct answer is B: Denial. Individuals with alcohol addiction often deny that they have a drinking problem and may become defensive when confronted about it. This sense of denial can be a significant barrier to seeking treatment. Co-dependency, referred to in choice A, is a relationship dynamic and is not the primary reason for avoiding treatment. Depression, as mentioned in choice C, is a common co-occurring condition with alcohol addiction but is not typically the main factor preventing treatment-seeking. Stigma, as in choice D, can act as a deterrent, but denial of the problem itself is usually the primary obstacle to seeking help.

4. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2 if necessary.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary.

Correct answer: D

Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (Choice A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (Choice B) is not required for early decelerations. Notifying the physician (Choice C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.

5. What must the evening nurse do to facilitate the client's ECT treatment the next morning?

• A. Ensure the patient signs an informed consent form
• B. Administer evening medications
• C. Ensure the patient gets a good night's sleep
• D. Provide dietary restrictions as per ECT protocol

Correct answer: A

Rationale: For electroconvulsive therapy (ECT) treatment, obtaining informed consent is crucial before the procedure. This ensures the patient is aware of the risks, benefits, and alternatives to the treatment. Administering medications, ensuring rest, and dietary restrictions are important but not directly related to the specific requirement of obtaining informed consent for ECT. The correct answer, ensuring the patient signs an informed consent form, is essential to uphold the patient's autonomy and ensure they have the necessary information to make an informed decision about their treatment.

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