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 nurse enters a client room to witness an informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

• A. Educate the client about the risks of refusing medications
• B. Complete an incident report
• C. Answer the client's question concerning the procedure
• D. Inform the provider that the client requires clarification about the procedure

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to inform the provider that the client requires clarification about the procedure. This ensures that the client fully understands the gastroscopy procedure before giving consent. Choice A is incorrect as the client's issue is not about refusing medications. Choice B is irrelevant as there is no incident to report. Choice C could be misleading as the nurse should not be providing information about the procedure but rather ensuring that the client gets the necessary clarification from the provider.

3. Which anatomic malformations are associated with Tetralogy of Fallot?

• A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
• B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
• C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
• D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow

Correct answer: D

Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.

4. A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?

• A. Alcoholism
• B. Renal insufficiency
• C. Hypoparathyroidism
• D. Tumor lysis syndrome

Correct answer: A

Rationale: The correct answer is A: Alcoholism. Alcoholism can lead to hypophosphatemia due to poor dietary intake and other factors. Excessive alcohol consumption can result in malnutrition, particularly a deficiency in phosphorus. Choices B, C, and D are unlikely to cause low serum phosphorus levels. Renal insufficiency is more likely to cause hyperphosphatemia, hypoparathyroidism is associated with hypocalcemia rather than hypophosphatemia, and tumor lysis syndrome typically presents with hyperphosphatemia due to the release of intracellular phosphate.

5. Select the type of skeletal fracture that is correctly paired with its description.

• A. A complete fracture: The fractured bone penetrates through the skin to the skin surface.
• B. A pathological fracture: A fracture that results from some physical trauma.
• C. A greenstick fracture: This bends but does not fracture the bone.
• D. An avulsion fracture: A fracture that pulls a part of the bone from the tendon or ligament

Correct answer: D

Rationale: The correct answer is D. An avulsion fracture occurs when a part of the bone is pulled away by a tendon or ligament. Choice A is incorrect because it describes an open fracture where the bone penetrates the skin. Choice B is incorrect as a pathological fracture results from an underlying disease weakening the bone, not physical trauma. Choice C is incorrect as a greenstick fracture involves the bone bending but not completely breaking.

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