Nursing Elites

1. A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

• A. I hope I can adjust to using crutches while I am recovering.
• B. I am worried about taking care of my toddler at home.
• C. I just don't think I can handle looking at my leg.
• D. I am not sure how I will pay for all the therapy I will need.

Correct answer: A

Rationale: The client's statement about adjusting to using crutches while recovering suggests a potential need for occupational therapy referral. Occupational therapists assist individuals in regaining independence in activities of daily living, including mobility aids and adaptations. Choices B, C, and D are more indicative of emotional or financial concerns and may require referrals to other healthcare professionals like counselors or financial advisors, rather than occupational therapists.

2. Which of the following healthcare providers can legally have access to all, or part, of a patient's medical record because they have a 'need to know'? Select one that does not apply.

• A. Student nurses caring for a particular patient
• B. Registered nurses when they are not caring for a particular patient
• C. The Vice President for nursing who is investigating a patient fall
• D. Licensed practical nurses caring for a particular patient

Correct answer: B

Rationale: Student nurses, licensed practical nurses, the Vice President for nursing investigating a fall, and quality assurance nurses have a 'need to know' basis to access patient records. Registered nurses who are not directly involved in the care of a patient do not have a legitimate reason or 'need to know' to access that patient's medical records, making choice B the correct answer. The Vice President for nursing investigating a specific incident and licensed practical nurses directly involved in a patient's care have legitimate reasons to access the medical records, ensuring continuity and quality of care.

3. Your client is adversely affected with fever, night sweats, occult hematuria, tenderness of the spleen, and Osler's nodes. What disorder would you most likely suspect?

• A. Tuberculosis
• B. AIDS/HIV
• C. Pericarditis
• D. Endocarditis

Correct answer: D

Rationale: The client is likely suffering from endocarditis based on the symptoms described. Endocarditis is characterized by fever, night sweats, hematuria, splenomegaly (tenderness of the spleen), and Osler's nodes (painful nodules on the pads of the fingers or toes). While tuberculosis and AIDS/HIV can present with some similar symptoms, the presence of Osler's nodes is more specific to endocarditis. Pericarditis typically presents with chest pain, not the combination of symptoms seen in this case.

4. Which of the following assessment tools is used to determine the patient's level of consciousness?

• A. The Snellen Scale
• B. The Norton Scale
• C. The Morse Scale
• D. The Glasgow Scale

Correct answer: D

Rationale: The correct answer is D, The Glasgow Scale. The Glasgow Coma Scale is specifically designed to assess a patient's level of consciousness by evaluating eye opening, verbal response, and motor response. Choices A, B, and C are incorrect because the Snellen Scale is used for vision testing, the Norton Scale is used for assessing the risk of pressure sores, and the Morse Scale is used for evaluating a patient's risk of falling, not for determining the level of consciousness.

5. Which anatomic malformations are associated with Tetralogy of Fallot?

• A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
• B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
• C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
• D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow

Correct answer: D

Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.

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