Nursing Elites

1. A patient has been admitted to the hospital with an L4-5 HNP diagnosis. After 24 hours, the patient is able to ambulate with assistance and has reduced muscle spasms. Which of the following medications was the most beneficial in changing the patient's mobility status?

• A. Mivacron
• B. Atropine
• C. Bethanechol
• D. Flexeril

Correct answer: D

Rationale: The correct answer is Flexeril. Flexeril is a muscle relaxant commonly used to treat acute muscle pain and spasms. In this scenario, the patient experiencing reduced muscle spasms and improved mobility after taking Flexeril indicates its effectiveness. Choice A, Mivacron, is a neuromuscular blocking agent that is not typically used for muscle spasms or pain relief. Choice B, Atropine, is a medication used to treat certain types of nerve agent and pesticide poisonings, not muscle spasms. Choice C, Bethanechol, is a medication that stimulates bladder contractions and is not indicated for muscle spasms or mobility improvement.

2. Which of the following food selections would need to be removed from a tray for a client recovering from thyroidectomy?

• A. Fresh apple
• B. V8 juice
• C. Mustard greens
• D. Ice cream

Correct answer: A

Rationale: The correct answer is a fresh apple. After a thyroidectomy, it is important to avoid hard and crunchy foods like apples due to the proximity of the esophagus to the surgical site. Apples can be difficult to chew and swallow, posing a risk of injury or discomfort to the patient. V8 juice, mustard greens, and ice cream are softer options that would be more suitable for a client recovering from thyroidectomy.

3. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:

• A. one commercially prepared glucose tablet
• B. two hard candies
• C. 4-6 ounces of fruit juice
• D. 2-3 teaspoons of honey

Correct answer: D

Rationale: The correct immediate intervention for hypoglycemia is to provide 10-15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2-3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4-6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.

4. A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:

• A. Plantar fasciitis.
• B. Hallux valgus.
• C. Hammertoe.
• D. Morton's neuroma.

Correct answer: D

Rationale: The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing pain and difficulty walking. Hallux valgus is commonly known as a bunion, involving a bony bump at the base of the big toe. Hammertoe is a condition where one toe is bent abnormally at the middle joint, resembling a hammer. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not by a mass causing difficulty walking. Therefore, options A, B, and C are incorrect as they do not describe a mass in the foot leading to difficulty walking, unlike Morton's neuroma.

5. A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that he lost consciousness for 1-2 minutes. On admission, the client's Glasgow Coma Scale (GCS) was 14. The GCS is now 12. The nurse should:

• A. Re-assess in 15 minutes
• B. Stimulate the client with a sternal rub
• C. Administer Tylenol with codeine for a headache
• D. Notify the physician

Correct answer: D

Rationale: A decrease in the Glasgow Coma Scale (GCS) score from 14 to 12 indicates a significant neurological change in the client's condition. This change can be indicative of a deterioration in the client's neurological status, possibly due to intracranial bleeding or swelling. It is crucial for the nurse to notify the physician immediately to ensure prompt evaluation and intervention. Re-assessing in 15 minutes or stimulating the client with a sternal rub are not appropriate actions in this situation as they do not address the underlying cause of the decrease in GCS. Administering Tylenol with codeine for a headache is also not recommended without further assessment and evaluation of the client's condition.

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