Nursing Elites

1. When should rehabilitation services begin?

• A. when the client enters the health care system.
• B. after the client requests rehabilitation services.
• C. after the client's physical condition stabilizes.
• D. when the client is discharged from the hospital.

Correct answer: A

Rationale: Rehabilitation services should begin when the client enters the health care system to ensure early intervention and optimal outcomes. Initiating rehabilitation early can prevent complications, maximize recovery potential, and improve overall health outcomes. Choice B is incorrect because delaying rehabilitation until the client requests it may result in missed opportunities for timely intervention. Choice C is incorrect as waiting for the client's physical condition to stabilize can lead to unnecessary delays in starting the rehabilitation process, potentially slowing down recovery progress. Choice D is incorrect because starting rehabilitation only after discharge can hinder the recovery process by missing out on crucial early stages of intervention and support.

2. A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?

• A. Asking the client to stick out his or her tongue and watching for tremors
• B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
• C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
• D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

Correct answer: D

Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.

3. A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

• A. Testing for the strength of each muscle joint
• B. Percussing at the location of the median nerve
• C. Checking for repetitive movements in the joints
• D. Asking the client to flex the wrist 90 degrees while holding the hands back to back

Correct answer: B

Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.

4. Which of the following vaccines is not part of the regular schedule of immunizations for children?

• A. DTaP
• B. MMR
• C. Hib
• D. hepatitis A

Correct answer: D

Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.

5. After reviewing the child's immunization record, which scheduled vaccine should the nurse prepare to administer next?

• A. Hib
• B. IPV
• C. MMR
• D. DTaP

Correct answer: D

Rationale: The correct answer is DTaP. DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Since the child has only received three doses of this vaccine, the next dose of DTaP should be administered. The other options are incorrect because Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months; IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age; MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age.

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