Nursing Elites

1. During an escharotomy on a patient with a burn injury, what is the purpose of this procedure?

• A. To release pressure and improve circulation in the affected area
• B. To remove dead tissue from the burn area
• C. To improve breathing by reducing skin tightness
• D. To prevent infection in the burned area

Correct answer: A

Rationale: Corrected Question: During an escharotomy on a patient with a burn injury, the purpose of this procedure is to release pressure and improve circulation in the affected area. This intervention is crucial in severe burns where the formation of eschar (dead tissue) can lead to increased pressure, compromising circulation and potentially causing further tissue damage. Choices B, C, and D are incorrect because escharotomy specifically aims to address pressure and circulation issues in severe burn injuries, rather than removing dead tissue, improving breathing, or preventing infection.

2. What are the expected signs of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe headache and confusion
• C. Elevated blood pressure and bradycardia
• D. Bradycardia and altered pupil response

Correct answer: A

Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.

3. What lab value should be prioritized in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Hemoglobin levels
• C. Serum albumin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. In a patient with HIV, monitoring the CD4 T-cell count is crucial as it reflects the status of the immune system. A CD4 T-cell count below 200 cells/mm3 indicates severe immunocompromise and risk of opportunistic infections. Hemoglobin levels (choice B) are important for assessing anemia but do not directly reflect the immune status in HIV patients. Serum albumin levels (choice C) are indicators of nutritional status and inflammation, not specific to HIV disease progression. White blood cell count (choice D) may fluctuate due to various conditions and is not as specific as the CD4 T-cell count in assessing HIV progression.

4. A nurse at a provider's office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective?

• A. I don't have muscle spasms as frequently.
• B. I haven't gotten any colds, even though it is flu season.
• C. I feel like my nerve pain has improved.
• D. It is easier to urinate now.

Correct answer: A

Rationale: The correct answer is A: 'I don't have muscle spasms as frequently.' Dantrolene is a medication that relaxes skeletal muscles and is commonly prescribed to treat muscle spasms in clients with multiple sclerosis. Therefore, a reduction in muscle spasms frequency would be an indication of the medication's effectiveness. Choices B, C, and D are incorrect because dantrolene is not indicated for preventing colds, improving nerve pain, or easing urination. The focus should be on the medication's intended purpose, which is to address muscle spasms in clients with multiple sclerosis.

5. What is the correct action when a patient reports cramping during enema administration?

• A. Lower the height of the solution container
• B. Increase the flow of the enema solution
• C. Stop the procedure and remove the tubing
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: The correct action to take when a patient reports cramping during enema administration is to lower the height of the solution container. Lowering the height reduces the pressure and speed of the solution entering the rectum, alleviating cramping. Increasing the flow of the enema solution (Choice B) can worsen the discomfort. Stopping the procedure and removing the tubing (Choice C) is not necessary unless there are severe complications. Continuing the enema at a slower rate (Choice D) may not effectively address the immediate cramping issue and could still cause discomfort to the patient.

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