Nursing Elites

1. A client with a history of chronic alcoholism presents to the emergency department with a complaint of double vision. Which cranial nerve is most likely involved?

• A. Cranial nerve I (Olfactory)
• B. Cranial nerve III (Oculomotor)
• C. Cranial nerve VI (Abducens)
• D. Cranial nerve VII (Facial)

Correct answer: C

Rationale: The correct answer is Cranial nerve VI (Abducens). Chronic alcoholism can lead to damage to the abducens nerve, which controls the lateral movement of the eye. This damage can result in symptoms like double vision. Cranial nerve I (Olfactory) is responsible for the sense of smell and is not related to eye movement. Cranial nerve III (Oculomotor) controls most of the eye movements but is less likely to be affected in chronic alcoholism than the abducens nerve. Cranial nerve VII (Facial) is responsible for facial movements and is not associated with double vision.

2. 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.

3. Which of the following statements indicates more teaching is needed regarding secondary lymph organs? ________is/are a secondary lymph organ.

• A. The spleen
• B. Peyer's patches
• C. Adenoids
• D. The liver

Correct answer: D

Rationale: The correct answer is D, 'The liver.' The liver is not a secondary lymph organ. Secondary lymph organs are primarily involved in the immune response, such as the spleen, Peyer's patches, and adenoids. The spleen filters blood and is essential for immune function. Peyer's patches are located in the small intestine and help protect against pathogens. Adenoids are located in the throat and play a role in immune defense. Therefore, the liver is the incorrect choice as it is not part of the secondary lymph organ system.

4. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:

• A. psychotherapy.
• B. total abstinence.
• C. Alcoholics Anonymous (AA).
• D. aversion therapy.

Correct answer: B

Rationale: The correct answer is B: total abstinence. Total abstinence from alcohol is considered the most effective treatment for alcoholism. This approach eliminates the risk of relapse and helps individuals maintain sobriety. While psychotherapy can be beneficial in addressing underlying issues, total abstinence is crucial in overcoming alcohol addiction. Alcoholics Anonymous (AA) is a supportive group that can complement treatment, but it is not the only effective approach. Aversion therapy aims to create a negative association with alcohol but may not address the underlying causes of addiction, making total abstinence a more comprehensive and recommended approach.

5. Which of the following is a factor that leads to increased risk for dehydration in the elderly?

• A. More insensible losses
• B. Increase in muscle mass
• C. Decline in kidney function
• D. Decrease in fat

Correct answer: C

Rationale: The correct answer is C: Decline in kidney function. As people age, their kidneys may not work as effectively in conserving water and concentrating urine, leading to a higher risk of dehydration. Choice A is incorrect because more insensible losses do not directly relate to an increased risk of dehydration in the elderly. Choice B, an increase in muscle mass, is not a factor that leads to dehydration. Choice D, a decrease in fat, is also not a direct factor contributing to dehydration in the elderly.

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