Nursing Elites

1. The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?

• A. Irregular breathing patterns
• B. Minimal heartbeat, dilated pupils
• C. Relaxed muscles, regular breathing, constricted pupils
• D. Euphoria, drowsiness, dizziness

Correct answer: D

Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.

2. Rachel is a 48-year-old mother of three who has been admitted after a drug overdose in a failed suicide attempt. When she regains consciousness, she states that she is ashamed and embarrassed that she tried to take her own life. What is the most therapeutic response to Rachel's statement?

• A. It's a relief your children weren't left without a mother.
• B. What were you thinking?
• C. We're here to help patients who value life.
• D. I know life can be difficult. We're here to help you.

Correct answer: D

Rationale: The most therapeutic response to Rachel's statement is to provide non-judgmental support and hope. By acknowledging the patient's feelings of shame and embarrassment and offering help and understanding, the nurse can help Rachel maintain her self-esteem. Choice A is not therapeutic as it may unintentionally convey guilt or further shame. Choice B is judgmental and confrontational, which can create a barrier to open communication. Choice C is dismissive and does not address Rachel's emotional state. The correct response (Choice D) acknowledges the patient's struggle, offers support, and conveys empathy, aligning with the nurse's role to treat all patients with respect and dignity in challenging situations.

3. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?

• A. Physical therapy for muscle strengthening exercises
• B. Physical therapy for range of motion exercises
• C. Occupational therapy to help her with confusion
• D. Medications to help her sleep more

Correct answer: A

Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.

4. In which of the following examples would informed consent not be required?

• A. A patient is apprehensive about an upcoming surgery and chooses not to learn of the risks involved with the procedure.
• B. A child is rushed to the Emergency Room after falling from a third-story window.
• C. An adult in a coma in a mental health institution with no listed next of kin.
• D. Informed consent is not required in any of the above examples.

Correct answer: D

Rationale: In emergency situations where immediate treatment is necessary to prevent further harm or save a life, such as in option B where a child is rushed to the Emergency Room after a fall, informed consent may be waived to provide prompt care. In option A, though the patient is apprehensive about surgery and chooses not to learn the risks, informed consent is not required as it is the patient's right to refuse information. In option C, when an adult is in a coma with no next of kin listed, decisions may be made in the patient's best interest following legal and ethical guidelines. Therefore, informed consent is not needed in any of the scenarios presented.

5. Which of the following statements best describes compartment syndrome?

• A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
• B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
• C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
• D. An injury causes pain and swelling of the median plantar nerve.

Correct answer: B

Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.

Similar Questions