Nursing Elites

1. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)

• A. Obtain the pulses in all four extremities
• B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
• C. Determine the client’s orientation to person, place, and time
• D. B, C

Correct answer: D

Rationale: The correct choices are B and C. Assessing grasp strength and orientation to person, place, and time are essential components of a neurological assessment after a CVA. Pulse assessment in all four extremities is more relevant to circulatory assessment rather than neurological status. Therefore, option A is incorrect.

2. Which of the following statements does NOT apply to a nursing plan of care?

• A. It contains short-term goals
• B. It is developed by the patient's physician
• C. It must be continually evaluated
• D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

3. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

• A. Platelets
• B. Vitamin K
• C. Calcium
• D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin inhibits the action of vitamin K, which is essential for blood clotting. By interfering with the production of certain clotting factors, warfarin helps prevent blood clots. Choices A, C, and D are incorrect because warfarin primarily affects the vitamin K-dependent clotting factors and not platelets, calcium, or vitamin B12.

4. Short-bowel syndrome usually occurs when:

• A. The longitudinal muscles of the intestine contract
• B. More than 50% of the small intestine is surgically removed
• C. More than 50% of the large intestine is surgically removed
• D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome usually occurs when more than 50% of the small intestine is surgically removed. This condition results in malabsorption of nutrients and fluids due to the reduced length of the small intestine. Choice A is incorrect because the contraction of longitudinal muscles does not lead to short-bowel syndrome. Choice C is incorrect as short-bowel syndrome is primarily related to the small intestine, not the large intestine. Choice D is incorrect since decreased transit time due to infection or drugs is not a direct cause of short-bowel syndrome.

5. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison’s disease?

• A. Discuss the importance of tapering medications when discontinuing medication
• B. Explain that the dose will need to be decreased during times of stress or infection
• C. Instruct the client to take medication on an empty stomach with a glass of water
• D. Encourage the client to wear a MedicAlert bracelet and carry a card in the wallet

Correct answer: A

Rationale: The correct answer is to discuss the importance of tapering medications when discontinuing medication. Tapering glucocorticoids is crucial to prevent adrenal insufficiency, which can occur if the medication is stopped abruptly. Choice B is incorrect because it focuses on adjustments during stress or infection, not discontinuation. Choice C is unrelated to the management of glucocorticoids. Choice D is important for emergency identification but is not directly related to medication management.

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