Nursing Elites

1. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

• A. It is normal among adolescents.
• B. It indicates that the patient has an intact peripheral nervous system.
• C. It indicates that the patient has an intact central nervous system.
• D. It is not a normal finding.

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

2. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?

• A. Discuss time management strategies with the nurses
• B. Provide coverage for the nurses' breaks
• C. Determine the reasons the nurses are not taking scheduled breaks
• D. Review policies for taking scheduled breaks

Correct answer: C

Rationale: The correct answer is to determine the reasons the nurses are not taking scheduled breaks. This action is crucial as it allows the charge nurse to understand the underlying causes for the behavior. By identifying the reasons, the nurse can then address the root of the issue effectively. Option A is incorrect because discussing time management strategies may not address the specific reasons for not taking breaks. Option B is incorrect as providing coverage for breaks does not address the underlying cause of the issue. Option D is also incorrect as reviewing policies should come after understanding the reasons for the behavior.

3. While administering penicillin intravenously, you notice that the patient becomes hypotensive with a bounding, rapid pulse rate. What is the first action you should take?

• A. Decrease the rate of the intravenous medication flow.
• B. Increase the rate of the intravenous medication flow.
• C. Call the doctor.
• D. Stop the intravenous flow.

Correct answer: D

Rationale: The correct action to take when a patient becomes hypotensive with a bounding, rapid pulse rate after administering penicillin intravenously is to stop the intravenous flow immediately. This can help prevent further complications by discontinuing the administration of the medication that might be causing the adverse effects. Decreasing or increasing the rate of medication flow may not address the underlying issue of the patient's adverse reaction. While it's important to involve the healthcare provider in such situations, the immediate priority is to halt the administration of the medication.

4. What is the role of a nurse in patient education?

• A. Providing patients with necessary information to manage their health
• B. Limiting information to prevent confusion
• C. Using complex medical terminology
• D. Discouraging questions from patients

Correct answer: A

Rationale: The correct answer is A: Providing patients with necessary information to manage their health. Nurses play a crucial role in patient education by offering essential information to help patients understand and manage their health conditions. This empowers patients to make informed decisions about their health and improve their overall well-being. Choices B, C, and D are incorrect. Limiting information would hinder patient understanding and decision-making, using complex medical terminology can confuse patients, and discouraging questions goes against the essence of patient education.

5. Which of the following is considered normal for the neonate?

• A. Chest Circumference: 10 to 13 inches
• B. Length: 16 to 22 inches
• C. Weight: 1,500 to 4,000 g
• D. Head Circumference: 12.6 to 14.5 inches

Correct answer: D

Rationale: A normal head circumference for a neonate typically falls within the range of 12.6 to 14.5 inches. Choice A is incorrect because the chest circumference for a neonate is usually smaller. Choice B is incorrect as the length of a neonate is typically shorter. Choice C is incorrect as the weight of a neonate is usually measured in grams and falls within a different range.

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