Nursing Elites

1. You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?

• A. Falls
• B. Skin breakdown
• C. Apnea
• D. Lack of mobility

Correct answer: B

Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.

2. A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:

• A. Psychological abuse
• B. Abandonment
• C. Material exploitation
• D. Physical abuse

Correct answer: A

Rationale: The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.

3. While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?

• A. Abdominal respirations
• B. Inspiratory grunt
• C. Nasal flaring
• D. Cyanosis

Correct answer: A

Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.

4. Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing?

• A. Hyponatremia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypercalcemia

Correct answer: D

Rationale: The parathyroid glands regulate calcium, vitamin D, and phosphorus in the body. Hyperparathyroidism leads to excessive production of parathyroid hormone, causing the release of calcium from bones into the bloodstream, resulting in elevated blood calcium levels, known as hypercalcemia. This puts individuals at risk of developing complications such as kidney stones, bone pain, osteoporosis, and neuropsychiatric symptoms. The other options, hyponatremia, hypocalcemia, and hypermagnesemia, are not directly associated with hyperparathyroidism. Hyponatremia is low sodium levels in the blood, hypocalcemia is low calcium levels, and hypermagnesemia is high magnesium levels, which are not typically seen in hyperparathyroidism.

5. A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?

• A. Contact the state board of nursing licensure to report the offense
• B. Review the state scope of practice standards for nurses
• C. Ask another nurse to perform the task to learn the procedure
• D. Contact the house supervisor to make the decision on whether the nurse should perform the task

Correct answer: B

Rationale: When faced with a task that a nurse believes may be beyond their scope of practice, it is essential to refer to the state's specific scope of practice standards for nurses. This step is crucial as these standards can vary between states, providing clarity on what tasks are permissible. By reviewing these standards, the nurse can determine if the task falls within their scope of practice. Contacting the state board of nursing licensure to report the offense (Choice A) is premature and should only be considered if there is a serious violation after reviewing the scope of practice. Asking another nurse to perform the task (Choice C) does not address the issue of clarifying the scope of practice. Contacting the house supervisor (Choice D) may be necessary if the nurse cannot determine the appropriateness of the task based on the scope of practice standards.

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