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. What are the nursing interventions for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Administer antiplatelet therapy
• C. Check for signs of DVT and provide anticoagulation
• D. Administer aspirin and monitor for bleeding

Correct answer: A

Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.

3. How should a healthcare professional assess and manage a patient with dehydration?

• A. Assess skin turgor and monitor intake/output
• B. Encourage oral fluids only
• C. Administer IV fluids immediately
• D. Check for electrolyte imbalance and administer fluids

Correct answer: A

Rationale: The correct way to assess and manage a patient with dehydration is to assess skin turgor and monitor intake/output. Skin turgor assessment helps in evaluating the degree of dehydration, while monitoring intake/output aids in maintaining fluid balance. Encouraging oral fluids only (Choice B) may not be sufficient for moderate to severe dehydration as patients may need intravenous fluids (IV) to rapidly rehydrate. Administering IV fluids immediately (Choice C) is not always the first step unless the patient is severely dehydrated. Checking for electrolyte imbalance and administering fluids (Choice D) is important but comes after assessing skin turgor and intake/output in the management of dehydration.

4. What are the differences between Type 1 and Type 2 diabetes in terms of treatment?

• A. Type 1: Insulin therapy; Type 2: Lifestyle modifications and oral agents
• B. Type 1: Oral agents; Type 2: Insulin therapy
• C. Type 1: Insulin resistance; Type 2: Insulin deficiency
• D. Type 1: Exercise and diet; Type 2: Insulin only

Correct answer: A

Rationale: The correct answer is A because Type 1 diabetes necessitates insulin therapy, whereas Type 2 diabetes is managed with lifestyle modifications and oral agents. Choice B is incorrect because Type 1 diabetes does not use oral agents as a primary treatment. Choice C is incorrect as it describes the pathophysiology of diabetes types rather than their treatments. Choice D is incorrect because Type 2 diabetes management involves more than just insulin and includes lifestyle changes and oral medications.

5. A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?

• A. Store enough water for 3 days
• B. Maintain communication with family
• C. Prepare only non-perishable food
• D. Prepare multiple escape routes

Correct answer: A

Rationale: The correct answer is A: 'Store enough water for 3 days.' When preparing a home disaster supply kit, it is crucial to include enough water to last at least 3 days. This is because clean drinking water may not be readily available during a disaster situation. Choice B, 'Maintain communication with family,' is important for coordination but not directly related to preparing a supply kit. Choice C, 'Prepare only non-perishable food,' is also important but does not address the specific recommendation for water. Choice D, 'Prepare multiple escape routes,' is crucial for evacuation planning but does not pertain to the contents of a home disaster supply kit.

Similar Questions