Nursing Elites

1. When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?

• A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.

2. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?

• A. Document that the client responds to the painful stimulus.
• B. Observe the client's response to verbal stimulation.
• C. Place the client on seizure precautions for 24 hours.
• D. Report decorticate posturing to the health care provider.

Correct answer: A

Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.

3. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

• A. Instruct in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique to change the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

4. Which statement best describes the pathophysiology of dementia of the Alzheimer type?

• A. There is a genetic predisposition and dysregulation of neurotransmitters.
• B. The dementia is transient and secondary to a physical imbalance or disorder.
• C. Hypoxia and decreased perfusion of select areas of the brain cause tissue damage.
• D. The presence of amyloid plaques is associated with brain tissue destruction.

Correct answer: D

Rationale: In Alzheimer's disease, the accumulation of amyloid plaques in the brain is a hallmark feature. These plaques are associated with the destruction of brain tissue, contributing to the cognitive decline seen in dementia. Genetic predisposition and dysregulation of neurotransmitters are factors linked to the development of Alzheimer's disease, but the primary pathology lies in the amyloid plaques. Transient dementia is not characteristic of Alzheimer's disease, which is a progressive neurodegenerative disorder. Hypoxia and decreased perfusion are more typical of vascular dementia, where blood flow to the brain is compromised.

5. Which dysfunction of the reproductive system is associated with anorexia nervosa in females?

• A. Galactorrhea
• B. Gynecomastia
• C. Amenorrhea
• D. Premenstrual dysphoric disorder

Correct answer: C

Rationale: Amenorrhea (cessation of menses) is associated with anorexia nervosa in females due to endocrine imbalances resulting from depleted fat stores. Galactorrhea is a milky discharge from the nipples unrelated to normal breast milk production. Gynecomastia is swelling of breast tissue in males. Premenstrual dysphoric disorder occurs about 1 week before menses and includes mood swings, depression, fatigue, bloating, overeating, and difficulty focusing, resolving when menstruation starts. In the context of anorexia nervosa, the primary concern is the disruption of the menstrual cycle due to low body weight, leading to amenorrhea.

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