Nursing Elites

1. In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?

• A. ability to breathe
• B. pallor or cyanosis of the skin
• C. number of accompanying family members
• D. motor function

Correct answer: C

Rationale: During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.

2. A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?

• A. Report the incident to the nursing supervisor
• B. Confront the nurse who gave the enema and inform the nurse that she may face charges of battery
• C. Tell the client that the nurse did the right thing in giving the enema
• D. Contact the client's health care provider

Correct answer: A

Rationale: Battery is any intentional touching of a client without the client's consent, which violates the client's rights. If a nurse discovers such an incident, they should report it to the nursing supervisor. Confronting the nurse and threatening charges of battery could lead to unnecessary conflict. Telling the client that the nurse did the right thing is incorrect as it goes against the client's wishes. While the health care provider may need to be notified eventually, the first step should be reporting the incident to the nursing supervisor to address the violation appropriately.

3. The client asks the nurse not to tell anyone outside of the care team about his positive HIV diagnosis. What response is most appropriate?

• A. "I have to inform all clients on the unit of your diagnosis as it is transmissible."?
• B. "I will not communicate your diagnosis to anyone without your permission."?
• C. "Because this is a communicable disease, it may need to be reported to the CDC."?
• D. "You should not be concerned with who I share your diagnosis with."?

Correct answer: C

Rationale: The most appropriate response is C: "Because this is a communicable disease, it may need to be reported to the CDC."? It is important to uphold patient confidentiality, but in the case of certain communicable diseases like HIV, there are legal requirements for mandatory reporting to public health authorities such as the CDC. Option A is incorrect because it violates patient confidentiality and does not consider legal obligations. Option B, while respecting the client's wishes, may not align with the legal requirement for reporting certain communicable diseases. Option D is inappropriate as it dismisses the client's concerns and rights regarding their health information.

4. A client with which of the following conditions is at risk for developing a high ammonia level?

• A. renal failure
• B. psoriasis
• C. lupus
• D. cirrhosis

Correct answer: D

Rationale: Cirrhosis is the correct answer. In cirrhosis, the liver is unable to detoxify ammonia to urea, leading to an accumulation of ammonia in the blood. This can result in hepatic encephalopathy, a condition characterized by high ammonia levels affecting brain function. Renal failure (Choice A), psoriasis (Choice B), and lupus (Choice C) are not directly associated with an increased risk of high ammonia levels as seen in cirrhosis.

5. Which of the following is least important to test when assessing the client’s motor skills?

• A. strength
• B. knowledge of ergonomics
• C. balance
• D. coordination

Correct answer: B

Rationale: When assessing a client’s motor skills, it is crucial to evaluate their strength, balance, and coordination as these directly impact their motor abilities. Strength is essential to perform tasks, balance is required for stability, and coordination is necessary for smooth movements. However, knowledge of ergonomics, while beneficial for overall understanding, is not directly related to assessing motor skills. The focus should be on physical abilities rather than theoretical knowledge of ergonomics. Therefore, testing the client’s knowledge of ergonomics is the least important when evaluating their motor skills.

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