Nursing Elites

1. Which preventive measure can be employed to decrease the risk of compartment syndrome?

• A. The administration of a potassium-sparing diuretic for heart failure
• B. A bivalve cast for a skeletal fracture
• C. A cerebral diuretic to decrease intracranial pressure after a head injury
• D. A chest tube to restore normal intrathoracic pressure after a pneumothorax

Correct answer: B

Rationale: The correct answer is B. A bivalve cast can help decrease the risk of compartment syndrome by providing space for swelling, thus preventing the build-up of pressure within the muscles. Choices A, C, and D are incorrect because they are not directly related to preventing compartment syndrome. Choice A is more focused on managing heart failure, choice C on reducing intracranial pressure, and choice D on restoring intrathoracic pressure after a pneumothorax, which are not relevant to preventing compartment syndrome.

2. You are caring for a patient who has no cognitive functioning but only basic human functions such as opening the eyes and the sleep-wake cycle. What level of consciousness does this patient have?

• A. Obtunded
• B. A persistent vegetative state
• C. Locked-in syndrome
• D. Brain death

Correct answer: B

Rationale: A persistent vegetative state is characterized by the absence of cognitive functioning while basic human functions like the sleep-wake cycle are retained. In this state, the patient shows reflex movements and basic responses to stimuli but lacks awareness or higher mental functions. Choices A, C, and D are incorrect because: A) Obtunded refers to a decreased level of consciousness, not the absence of cognitive functioning. C) Locked-in syndrome is a condition where the patient is aware and awake but cannot move or communicate due to complete paralysis of nearly all voluntary muscles except for vertical eye movements and blinking. D) Brain death is the irreversible cessation of all brain activity, including the brainstem, leading to the loss of all functions of the brain.

3. Your client is adversely affected with fever, night sweats, occult hematuria, tenderness of the spleen, and Osler's nodes. What disorder would you most likely suspect?

• A. Tuberculosis
• B. AIDS/HIV
• C. Pericarditis
• D. Endocarditis

Correct answer: D

Rationale: The client is likely suffering from endocarditis based on the symptoms described. Endocarditis is characterized by fever, night sweats, hematuria, splenomegaly (tenderness of the spleen), and Osler's nodes (painful nodules on the pads of the fingers or toes). While tuberculosis and AIDS/HIV can present with some similar symptoms, the presence of Osler's nodes is more specific to endocarditis. Pericarditis typically presents with chest pain, not the combination of symptoms seen in this case.

4. A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

• A. File an incident report.
• B. Ask the client about his injuries with the son present.
• C. Ask the client's son to go to the waiting area.
• D. Treat and discharge the client

Correct answer: C

Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.

5. The wound irrigation process cleanses the wound and:

• A. Reduces the potential pain in the wound region or area.
• B. Stops the spread of infection by creating a 'clean' area.
• C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
• D. Allows for the introduction of medications in solution form.

Correct answer: D

Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.

Similar Questions