Nursing Elites

1. Which of the following is an example of low health literacy skills?

• A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
• B. A client cannot read an admission form to sign it
• C. A nurse cannot calculate the correct IV rate for Ringer's lactate
• D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine

Correct answer: B

Rationale: Low health literacy skills are exemplified by an individual's inability to comprehend health-related information. In this scenario, a client's inability to read an admission form to sign it indicates low health literacy. This lack of understanding can hinder their ability to make informed decisions about their healthcare. The other choices involve healthcare professionals and their knowledge or skills, not the health literacy of individuals seeking care.

2. A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:

• A. Avoid eating red meat for 3 days before the test
• B. Collect the stool sample from the toilet after having a bowel movement
• C. The stool does not need to be kept in a container with preservative
• D. A small part of the stool from two areas will be tested using a smear

Correct answer: B

Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.

3. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?

• A. Torticollis, with shortening of the sternocleidomastoid muscle
• B. Craniosynostosis, with premature closure of the cranial sutures
• C. Plagiocephaly, with flattening of one side of the head
• D. Hydrocephalus, with increased head size

Correct answer: A

Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.

4. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:

• A. Go get a blood pressure check within the next 15 minutes
• B. Check blood pressure again in two (2) months
• C. See the healthcare provider immediately
• D. Visit the healthcare provider within one (1) week for a BP check

Correct answer: A

Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.

5. Which of the following situations warrants a measurement for orthostatic hypotension?

• A. A 36-year-old male with a spinal injury
• B. An 86-year-old female with significantly altered mental status
• C. A 58-year-old female with near-syncope
• D. A 41-year-old male with acute deep vein thrombosis

Correct answer: C

Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.

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