Nursing Elites

1. A client has been admitted to the hospital with symptoms of Guillain-Barré syndrome. Which aspect of the client's condition would require priority monitoring?

• A. Monitoring oxygen saturation levels
• B. Monitoring for signs of respiratory compromise
• C. Monitoring for changes in consciousness
• D. Monitoring blood pressure closely

Correct answer: B

Rationale: In Guillain-Barré syndrome, respiratory muscle weakness can lead to respiratory compromise, making it crucial to prioritize monitoring for signs of respiratory distress. Monitoring oxygen saturation levels is important but is secondary to assessing for respiratory compromise in this condition. Changes in consciousness and monitoring blood pressure closely are not typically the priority in Guillain-Barré syndrome.

2. A patient is being treated for active tuberculosis with ethambutol (Myambutol). The patient states to the nurse that he cannot identify the red and green on the traffic lights when he is driving. Based on this finding, what medical intervention is most appropriate?

• A. Assess for photosensitivity.
• B. Discontinue ethambutol (Myambutol).
• C. Decrease the ethambutol (Myambutol) dose.
• D. Administer vitamin B.

Correct answer: A

Rationale: The correct answer is to assess for photosensitivity. Ethambutol can cause optic neuritis, leading to visual disturbances, including difficulty differentiating red and green colors. This is a sign of optic nerve damage and requires immediate evaluation. Discontinuing ethambutol may be necessary if optic neuritis is confirmed, but this decision should be made by a healthcare provider. Decreasing the dose of ethambutol may not address the visual changes. Administering vitamin B does not directly address the side effect caused by ethambutol.

3. Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse’s priority intervention?

• A. Contact the child’s parents and ask about the child’s injuries.
• B. Encourage the child to be honest about the injuries.
• C. Question the teacher about the child's injuries.
• D. Report suspicion of abuse to the proper authorities.

Correct answer: D

Rationale: The school nurse's priority intervention in this situation is to report suspicion of abuse to the proper authorities. Given the pattern of unexplained injuries and vague explanations provided by the child, it raises significant concerns for possible abuse. Reporting to the appropriate authorities is crucial to ensure the child's safety and well-being. Contacting the child's parents (Choice A) may not be appropriate if abuse is suspected, as it could potentially put the child at further risk. Merely encouraging the child to be honest (Choice B) does not address the immediate safety concerns. Questioning the teacher (Choice C) is not the appropriate initial action when abuse is suspected; reporting to authorities should take precedence.

4. Identify which conditions are due to excessive immune response.

• A. Allergies and onychomycosis
• B. Type II diabetes and smallpox
• C. Chronic renal failure and macular degeneration
• D. Allergies and rheumatoid arthritis

Correct answer: D

Rationale: The correct answer is D: Allergies and rheumatoid arthritis. Allergies are caused by an excessive immune response to harmless substances, while rheumatoid arthritis is an autoimmune disorder where the immune system attacks the body's tissues, leading to inflammation and joint damage. Choices A, B, and C are incorrect. Onychomycosis is a fungal infection of the nails, Type II diabetes is a metabolic disorder not primarily related to immune response, smallpox is a viral infection, chronic renal failure is a kidney condition, and macular degeneration is an eye disorder, none of which are directly linked to excessive immune response.

5. A patient is being treated with raloxifene (Evista) for osteoporosis. What should the nurse teach the patient about this medication?

• A. It is used as a selective estrogen receptor modulator to prevent bone loss.
• B. It works by decreasing bone formation and increasing bone resorption.
• C. It should be taken with food to reduce gastrointestinal side effects.
• D. It may cause weight gain and fluid retention.

Correct answer: C

Rationale: The correct answer is C. Raloxifene is a selective estrogen receptor modulator (SERM) used to prevent bone loss. It should be taken with food to reduce gastrointestinal side effects, not on an empty stomach. Choices A and B are incorrect because raloxifene is indeed a SERM that prevents bone loss, but it does not directly work by increasing bone formation or decreasing bone resorption. Choice D is incorrect as weight gain and fluid retention are not common side effects of raloxifene.

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