Nursing Elites

1. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

• A. Transport the client to the operating room without verifying informed consent
• B. Ask the anesthesiologist to sign the consent
• C. Obtain telephone consent from the facility administrator before the surgery
• D. Delay the surgery until the nurse can obtain informed consent

Correct answer: A

Rationale: In emergency situations where a client is unconscious and requires immediate surgery, implied consent applies. Implied consent allows healthcare providers, including nurses, to proceed with necessary treatment or surgery without formally verifying informed consent. Choice A is correct because the priority in this scenario is to ensure the client receives timely medical intervention to address life-threatening conditions. Choices B, C, and D are incorrect because in emergencies, waiting to obtain formal consent can delay critical treatment, risking the client's health and well-being.

2. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?

• A. Generalized rash over trunk
• B. Increased temperature
• C. Decreased level of consciousness
• D. Report of photophobia

Correct answer: C

Rationale: The correct answer is C: Decreased level of consciousness. In a client with meningitis, a decreased level of consciousness is a critical finding that should be reported immediately. This could indicate increased intracranial pressure or neurological deterioration, requiring prompt intervention. Choices A, B, and D are important in the assessment of meningitis but are not as immediately concerning as a decreased level of consciousness. A generalized rash over the trunk can be seen in meningococcal meningitis, an increased temperature is expected due to the inflammatory response, and photophobia is a common symptom due to meningeal irritation.

3. What does the mnemonic PERLA stand for in the assessment of the eyes?

• A. Pupils equally reactive to light and accommodation
• B. Patient eyes are equally recessed and responsive to light and acuity
• C. Patient eyes are equally responsive to light and acuity
• D. Pupils equally reactive to light and acuity

Correct answer: A

Rationale: The correct answer is A: 'Pupils equally reactive to light and accommodation.' PERLA is a mnemonic used in eye assessments to check for Pupils being equally reactive to Light and Accommodation. Choice B is incorrect as it includes irrelevant information about the eyes being recessed. Choice C is incorrect as it is missing the mention of pupils and accommodation. Choice D is incorrect as it misses the mention of accommodation.

4. Which patient is at greatest risk for papilledema?

• A. An elderly patient with cataracts and macular degeneration
• B. A male patient with hypothyroidism
• C. A male patient with hyperthyroidism
• D. An adolescent with a closed head injury

Correct answer: D

Rationale: An adolescent with a closed head injury is at the highest risk for papilledema due to increased intracranial pressure. Papilledema is often a consequence of elevated intracranial pressure, which can occur in conditions like head trauma. Choices A, B, and C do not directly correlate with an increased risk of papilledema compared to a closed head injury, which is more likely to lead to elevated intracranial pressure and subsequent papilledema.

5. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for further evaluation and possible intervention?

• A. A client who is at 28 weeks gestation and has a negative Coombs titer
• B. A client who is 39 weeks of gestation and has a negative contraction stress test
• C. A client who is at 35 weeks of gestation and has a biophysical profile of 6
• D. A client who is at 37 weeks of gestation and has an L/S ratio of 2:1

Correct answer: C

Rationale: A biophysical profile of 6 at 35 weeks of gestation indicates a need for further evaluation and possible intervention. A negative Coombs titer at 28 weeks gestation (Choice A) is within normal limits. A negative contraction stress test at 39 weeks gestation (Choice B) is expected as the pregnancy nears term. An L/S ratio of 2:1 at 37 weeks of gestation (Choice D) is consistent with fetal lung maturity.

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