Nursing Elites

1. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?

• A. The nurse ties the restraints in a square knot to prevent the client from untying them
• B. The restraints are attached to a movable portion of the bed
• C. The padded side of the restraint is applied next to the skin of the wrist
• D. The nurse assesses the client's distal circulation every 24 hours

Correct answer: C

Rationale: Restraint use must prioritize the safety of the client. When applying restraints around the wrists, the padded side should be placed against the skin to help prevent skin breakdown. Additionally, restraints should be secured in quick-release knots to ensure they can be removed rapidly in case of an emergency. Choice A is incorrect as restraints should not be tied in a way that could prevent quick removal. Choice B is incorrect because restraints should not be attached to a movable part of the bed to avoid unintentional movement. Choice D is incorrect as assessing distal circulation is important but is not directly related to the safe application of restraints.

2. A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. What rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?

• A. Controls stray electrical currents.
• B. Promotes efficient use of electricity.
• C. Shuts off the appliance if there is an electrical surge.
• D. Divides the electricity among the appliances in the room.

Correct answer: A

Rationale: A three-pronged plug functions as a ground to dissipate stray electrical currents. This helps prevent electrical shocks and ensures the safety of the user. Choice B is incorrect because the number of prongs on a plug does not impact the efficient use of electricity. Choice C is incorrect because a three-pronged plug does not shut off the appliance during an electrical surge; that role is typically fulfilled by surge protectors. Choice D is incorrect as a three-pronged plug does not divide electricity among appliances in a room; it primarily serves as a safety measure to handle excess electrical currents.

3. A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?

• A. Stand behind the client and prepare to catch them if they fall
• B. Assist the client to sit in the nearest chair or slide down along a wall
• C. Grasp the client under the arms and pull them upward
• D. Call for help from nearby staff

Correct answer: A

Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.

4. Which of the following is the most likely cause of constipation in a client?

• A. Postponing bowel movement when the urge to defecate occurs
• B. Intestinal infection
• C. Antibiotic use
• D. Food allergies

Correct answer: A

Rationale: The correct answer is to postpone bowel movement when the urge to defecate occurs. Clients who delay bowel movements by ignoring the urge to defecate or not evacuating promptly, such as in situations where they are not near a bathroom, are at higher risk of developing constipation. This behavior leads to a decrease in bowel movement frequency, slowed intestinal motility, and increased fecal water absorption, resulting in hard, dry stools that are difficult to pass. Intestinal infection (choice B), antibiotic use (choice C), and food allergies (choice D) are less likely to be direct causes of constipation compared to postponing bowel movements.

5. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child likely have?

• A. Acromegaly
• B. Marfan syndrome
• C. Hypopituitary dwarfism
• D. Achondroplastic dwarfism

Correct answer: C

Rationale: Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.

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