Nursing Elites

1. Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)

• A. Age
• B. Blood pressure
• C. Respiratory rate
• D. Oxygen saturation

Correct answer: D

Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.

2. Which entry in the medical record best meets the requirement for problem-oriented charting?

• A. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV."?
• B. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."?
• C. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV."?
• D. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"?

Correct answer: B

Rationale: Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The correct answer demonstrates problem-oriented charting by following this structure. Choice A, C, and D do not follow the problem-oriented charting format and instead offer examples of different documentation styles such as PIE charting, focus documentation, and narrative documentation, respectively. Therefore, choice B is the best example of problem-oriented charting among the options provided.

3. A physician suspects a patient may have pancreatitis. Which of the following tests would be most appropriate to diagnose this condition?

• A. CK and Troponin
• B. BUN and Creatinine
• C. Amylase and Lipase
• D. HDL and LDL Cholesterol Levels

Correct answer: C

Rationale: To diagnose pancreatitis, testing amylase and lipase levels is crucial. Amylase and lipase are enzymes produced by the pancreas that help digest carbohydrates and lipids. In pancreatitis, these enzymes are released in high amounts into the bloodstream due to pancreatic inflammation or damage. Elevated levels of amylase and lipase in blood tests strongly indicate pancreatitis. Choice A, CK and Troponin, are cardiac markers used in diagnosing heart conditions like myocardial infarction, not pancreatitis. Choice B, BUN and Creatinine, are kidney function tests, not specific to pancreatitis. Choice D, HDL and LDL Cholesterol Levels, are lipid profile tests used to assess cardiovascular health, not for diagnosing pancreatitis.

4. A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse expects to provide teaching about which client problem?

• A. Odor
• B. Nausea
• C. Malaise
• D. Diarrhea

Correct answer: A

Rationale: Encopresis is the repeated voluntary or involuntary passage of feces of normal or near-normal consistency in places not appropriate for that purpose according to the individual's own sociocultural setting. Signs of encopresis include evidence of soiled clothing, scratching or rubbing the anal area due to irritation, fecal odor without apparent awareness by the child, and social withdrawal. Teaching about odor is essential to address the issue of encopresis. Choices B, C, and D are incorrect because encopresis is not typically associated with nausea, malaise, or diarrhea. Therefore, teaching about these symptoms would not be relevant in the context of encopresis.

5. A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

• A. Back Pain
• B. Fever and Chills
• C. Risk for Bleeding
• D. Dizziness

Correct answer: C

Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.

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