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. 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.

3. During which stage of anesthesia is a patient most likely to experience involuntary motor activity?

• A. Stage I
• B. Stage II
• C. Stage III
• D. Stage VI

Correct answer: B

Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements. Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur. Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage. Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.

4. What does the mnemonic PERLA stand for in the assessment of the eyes?

• A. Pupils equally reactive to light and accommodation
• B. Patient eyes are equally recessed and responsive to light and acuity
• C. Patient eyes are equally responsive to light and acuity
• D. Pupils equally reactive to light and acuity

Correct answer: A

Rationale: The correct answer is A: 'Pupils equally reactive to light and accommodation.' PERLA is a mnemonic used in eye assessments to check for Pupils being equally reactive to Light and Accommodation. Choice B is incorrect as it includes irrelevant information about the eyes being recessed. Choice C is incorrect as it is missing the mention of pupils and accommodation. Choice D is incorrect as it misses the mention of accommodation.

5. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?

• A. Assault
• B. False imprisonment
• C. Battery
• D. Libel

Correct answer: C

Rationale: The correct answer is C, 'Battery.' Administering the injection without the client's consent constitutes battery. Assault involves the threat of harm, not the actual act. False imprisonment is restraining a client against their will, which does not apply here. Libel refers to a false written statement, which is not relevant in this scenario.

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