Nursing Elites

1. The nurse is planning care for a client with damage to the vestibular area of the vestibulocochlear nerve. What should the nurse include in the plan of care? Select all that apply.

• A. Assistance with ambulation
• B. Regular hearing tests
• C. Monitoring for nausea
• D. Vision assessments

Correct answer: A

Rationale: Damage to the vestibular area affects balance and may cause nausea. Therefore, the nurse should include assistance with ambulation in the care plan to help the client maintain stability while walking. Regular hearing tests (choice B) are not directly related to damage in the vestibular area of the vestibulocochlear nerve. While nausea (choice C) may occur due to vestibular damage, monitoring for it alone is not as essential as providing assistance with ambulation. Vision assessments (choice D) are important for assessing visual function but are not the priority when dealing with vestibular issues.

2. Women who have breast cancer due to a BRCA1 gene mutation are usually:

• A. positive for human epidermal growth factor receptor 1 and 2.
• B. negative for estrogen receptor.
• C. positive for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2.
• D. negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2.

Correct answer: D

Rationale: Women with breast cancer due to a BRCA1 gene mutation commonly have a triple-negative breast cancer subtype, which means they are negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2). This subtype tends to be more aggressive and harder to treat. Choice A is incorrect as they are typically negative for HER2. Choice B is incorrect because they are usually negative for estrogen receptor. Choice C is incorrect as they are usually negative for progesterone receptor and HER2.

3. What does a client's symptoms of headache, vomiting, blurred vision, and loss of consciousness following a concussion indicate?

• A. Increased intracranial pressure
• B. Lower extremity compartment syndrome
• C. Consuming too much food at once
• D. Improved kidney function

Correct answer: A

Rationale: The symptoms of headache, vomiting, blurred vision, and loss of consciousness following a concussion are indicative of increased intracranial pressure. These symptoms suggest a serious condition that can occur after head trauma, requiring immediate medical attention. Lower extremity compartment syndrome presents with symptoms related to pressure build-up in the muscles of the legs, not the head. Consuming too much food at once does not manifest with these neurological symptoms. Improved kidney function would not present with symptoms such as headache, vomiting, blurred vision, and loss of consciousness.

4. The healthcare provider is caring for a client with an altered level of consciousness and needs to assess the withdrawal reflex. Which action should the healthcare provider perform?

• A. Apply a painful stimulus to see if the client pulls away.
• B. Check for pupil response to light.
• C. Assess the client's response to verbal commands.
• D. Observe the client's reaction to a cold stimulus.

Correct answer: A

Rationale: The withdrawal reflex is assessed by applying a painful stimulus and observing if the client pulls away. This response indicates a functioning reflex arc. Choices B, C, and D are incorrect as they do not involve testing the withdrawal reflex specifically. Checking for pupil response to light assesses the pupillary reflex, assessing the client's response to verbal commands evaluates their cognitive function, and observing the client's reaction to a cold stimulus tests for a different type of sensory response.

5. After a thoracentesis on a client with a pleural effusion, which nursing intervention is most important post-procedure?

• A. Monitor for signs of infection.
• B. Assess for signs of bleeding or hematoma.
• C. Monitor vital signs and respiratory status.
• D. Instruct the client to rest and limit physical activity.

Correct answer: B

Rationale: The correct answer is to assess for signs of bleeding or hematoma. After a thoracentesis, it is crucial to monitor for any bleeding or hematoma formation at the puncture site, as this can lead to complications. Monitoring for signs of infection (Choice A) is essential but is usually a delayed concern compared to the immediate risk of bleeding post-procedure. While monitoring vital signs and respiratory status (Choice C) is important, assessing for bleeding takes precedence to address any immediate complications. Instructing the client to rest and limit physical activity (Choice D) is relevant for general post-procedure care but is not the most critical intervention in this scenario.

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