Nursing Elites

1. A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?

• A. When descending stairs, I will first shift my weight to my right (unaffected) leg.
• B. I will use crutches to support my weight on my left leg.
• C. When ascending stairs, I will lead with my left leg.
• D. I will keep my crutches under my arms for support.

Correct answer: A

Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.

2. A healthcare professional is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the professional obtain to assess for this condition?

• A. Thermometer
• B. Elastic stockings
• C. Blood pressure cuff
• D. Sequential compression devices

Correct answer: C

Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.

3. The caregiver is assessing an 8-month-old child with atonic cerebral palsy. Which statement from the caregiver supports the presence of this problem?

• A. When I place my finger in the left hand, the baby does not respond with a grasp.
• B. My baby does not seem to track objects when I move toys in front of their face.
• C. When it thundered loudly last night, the baby did not even startle.
• D. When I place the baby in a supine position, that's how I find the baby.

Correct answer: D

Rationale: The statement 'When I place the baby in a supine position, that's how I find the baby' supports the presence of atonic cerebral palsy. In this type of cerebral palsy, the child may have poor muscle tone, making it difficult for them to roll from a back-lying position. This inability to roll indicates a lack of muscle tone, which is a characteristic feature of atonic cerebral palsy. Choices A, B, and C do not directly relate to the muscle tone issues typical of atonic cerebral palsy. Choice A focuses on a lack of grasp response, which may suggest motor issues but not specifically atonic cerebral palsy. Choice B refers to visual tracking, and choice C is about the startle reflex, neither of which are defining characteristics of atonic cerebral palsy.

4. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?

• A. “I kind of like this boy in my class, but he doesn’t like me back.”
• B. “I want to hang out with the kids in the science club, but the jocks pick on them.”
• C. “I am so fat, I skip meals to try to lose weight.”
• D. “My dad wants me to be a lawyer like him, but I just want to dance.”

Correct answer: C

Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.

5. A healthcare professional is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?

• A. A patient who is afebrile
• B. A patient who is diaphoretic
• C. A patient with strong pedal pulses
• D. A patient with adequate skin turgor

Correct answer: B

Rationale: Excessive moisture on the skin, as seen in a diaphoretic patient, can lead to impaired skin integrity. Diaphoresis softens epidermal cells, promotes bacterial growth, and can cause skin maceration. Afebrile status, strong pedal pulses, and adequate skin turgor are not directly associated with an increased risk of impaired skin integrity. Afebrile indicates the absence of fever, not a risk to skin integrity. Strong pedal pulses suggest good circulation, which is beneficial for skin health. Adequate skin turgor is a sign of good hydration and skin elasticity, indicating a lower risk of impaired skin integrity.

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