Nursing Elites

1. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

• A. Nuchal rigidity
• B. Carotid bruit
• C. Jugular vein distention
• D. Palpable cervical lymph node

Correct answer: B

Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.

2. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

• A. Capillary refill takes > 3 seconds.
• B. Episodes of vertigo and loss of balance.
• C. Average daily output of 1200 ml.
• D. Pulse rate of 110 beats/minute and dyspnea upon exertion.

Correct answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

3. Which other congenital defects are common in children with Down syndrome?

• A. Hypospadias
• B. Pyloric stenosis
• C. Heart defects
• D. Hip dysplasia

Correct answer: C

Rationale: The correct answer is C: Heart defects. Many children with Down syndrome are born with congenital heart defects. These heart abnormalities are more prevalent in individuals with Down syndrome than in the general population. Choices A, B, and D are incorrect because while they may be congenital defects in children, they are not commonly associated with Down syndrome. Hypospadias is a urogenital condition, pyloric stenosis affects the stomach, and hip dysplasia involves the hip joint, but these are not typically seen as frequently as heart defects in children with Down syndrome.

4. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)

• A. Verify pedal pulses using a doppler pulse device.
• B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
• C. Evaluate the application of the splint to the left leg.
• D.

Correct answer: C

Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.

5. When interacting with the parents of a SIDS infant, the nurse should attempt to assist the parents with:

• A. Encouraging the parents to have another baby.
• B. Encouraging the parents to remain stoic.
• C. Allaying feelings of guilt and blame.
• D. Learning how the event could have been prevented.

Correct answer: C

Rationale: The correct answer is C: Allaying feelings of guilt and blame. When parents experience the loss of a SIDS infant, they often struggle with intense feelings of guilt and self-blame. The nurse's role is to provide emotional support and help alleviate these feelings. Choices A and B are incorrect as encouraging the parents to have another baby or to remain stoic is not appropriate or helpful in this situation. Choice D is also incorrect because focusing on how the event could have been prevented may exacerbate feelings of guilt and is not the immediate priority in supporting grieving parents.

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