Nursing Elites

1. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

• A. hypothalamus.
• B. thalamus.
• C. cortex.
• D. medulla.

Correct answer: A

Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.

2. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

• A. "I should raise him to a sitting position."?
• B. "I should check for a fecal impaction."?
• C. "I should look for a kink in the urinary catheter tubing."?
• D. "I should observe whether symptoms worsen."?

Correct answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

3. An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:

• A. internationally.
• B. in the state of Colorado only.
• C. in the continental United States.
• D. in the county of origination only.

Correct answer: B

Rationale: The correct answer is 'in the state of Colorado only.' Advance directive protocols and documents are specific to each state's laws and regulations. Choice A is incorrect as advance directives are not universally recognized internationally. Choice C is incorrect as the legal validity of an advance directive is limited to the state in which it was created. Choice D is incorrect as the legal reach of an advance directive typically extends throughout the state of origination, not just the county.

4. After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?

• A. You can lie down in 1 hour.
• B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
• C. You can lie down in about 30 minutes.
• D. Yes, feel free to lie down.

Correct answer: C

Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.

5. When making an occupied bed, what is important for the nurse to do?

• A. keep the bed in the low position.
• B. use a bath blanket or top sheet for warmth and privacy
• C. constantly keep side rails raised on both sides.
• D. move back and forth from one side to the other when adjusting the linens.

Correct answer: B

Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.

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