Nursing Elites

1. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?

• A. Decerebrate posturing.
• B. Hypervigilance.
• C. Absence of deep tendon reflexes.
• D. Glasgow Coma Scale score of 15.

Correct answer: A

Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.

2. A nurse is teaching a client with hypertension about using a blood pressure monitor. Which of the following instructions should the nurse include?

• A. Take your blood pressure after eating
• B. Sit quietly for 5 minutes before taking your blood pressure
• C. Use a blood pressure cuff that is too small
• D. Take your blood pressure while standing

Correct answer: B

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before taking their blood pressure. This is important because sitting quietly helps stabilize the heart rate, leading to a more accurate reading. Choice A is incorrect because taking blood pressure after eating can affect the readings. Choice C is wrong because using a blood pressure cuff that is too small can provide inaccurate readings. Choice D is also incorrect as blood pressure should be taken in a seated position for accurate results.

3. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?

• A. Use the cane on the stronger side of the body
• B. Maintain two points of support on the floor at all times
• C. Advance the cane and the strong leg together
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

4. What is the priority nursing intervention for a patient with chest pain?

• A. Administer nitroglycerin
• B. Assess pain level
• C. Monitor vital signs
• D. Provide oxygen therapy

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.

5. What is the primary intervention for sepsis?

• A. Administer IV antibiotics
• B. Monitor blood pressure
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.

Similar Questions