Nursing Elites

1. A client with a history of epilepsy is admitted with status epilepticus. Which medication should the nurse prepare to administer?

• A. Acetaminophen (Tylenol)
• B. Lorazepam (Ativan)
• C. Phenytoin (Dilantin)
• D. Carbamazepine (Tegretol)

Correct answer: B

Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine such as lorazepam (Ativan) to rapidly terminate the seizure activity. Lorazepam acts quickly and effectively in stopping seizures. Phenytoin (Dilantin) is often used as a second-line agent for status epilepticus, and carbamazepine (Tegretol) is not typically indicated for the acute treatment of status epilepticus. Acetaminophen (Tylenol) is a pain reliever and antipyretic but is not used in the treatment of status epilepticus.

2. The nurse obtains a pulse rate of 89 beats/min for an infant before administering digoxin (Lanoxin). What action should the nurse take?

• A. Administer the medication.
• B. Hold the medication and contact the healthcare provider.
• C. Double the dose.
• D. Increase fluid intake.

Correct answer: B

Rationale: The correct answer is to hold the medication and contact the healthcare provider. Bradycardia (pulse rate less than 100 beats/minute) is an early sign of digoxin toxicity. It is essential to withhold digoxin and notify the healthcare provider to prevent potential adverse effects. Administering the medication (Choice A) could exacerbate the toxicity. Doubling the dose (Choice C) is inappropriate and dangerous. Increasing fluid intake (Choice D) is not indicated in this situation and does not address the issue of digoxin toxicity.

3. The school nurse is preparing a presentation on the importance of physical activity for elementary school students. Which benefit should the nurse emphasize?

• A. Improved academic performance
• B. Increased social interactions
• C. Enhanced physical strength
• D. Better sleep patterns

Correct answer: A

Rationale: The correct answer is A: Improved academic performance. Physical activity has been shown to improve academic performance by enhancing concentration and cognitive function. This benefit is particularly important for elementary school students who are developing foundational skills. Choice B, increased social interactions, while important for overall development, may not directly relate to the academic aspect that the nurse is focusing on. Choice C, enhanced physical strength, is a valid benefit of physical activity but may not be as relevant to academic performance as the ability to concentrate and learn. Choice D, better sleep patterns, is also a valuable outcome of physical activity but is not as directly linked to academic performance as improved cognitive function.

4. The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2020 objectives are being addressed?

• A. the absenteeism rate has increased greatly over the past two years
• B. during the last year fewer firearms were retrieved on school property
• C. the number of requests for pregnancy testing is higher than last year
• D. decline in the number of students enrolled in school during the year

Correct answer: B

Rationale: The correct answer is B. A decrease in firearms retrieved on school property is a positive indication that the Healthy People 2020 objectives are being addressed. This finding suggests progress in reducing violence and improving safety in schools, which aligns with the goals of promoting overall health and safety among adolescents. Choices A, C, and D do not directly relate to the Healthy People 2020 objectives. Increased absenteeism, higher requests for pregnancy testing, and a decline in student enrollment do not necessarily reflect the specific health and safety goals outlined in Healthy People 2020.

5. The wife of an older adult man who has had diabetes mellitus for the past 10 years reports to the home health nurse that her husband fell yesterday while taking his daily walk in the neighborhood. He has a bruised hand and a small abrasion on his left knee. The nurse assesses that his neurologic vital signs are stable. To reduce the risk for future falls, which assessment is most important for the nurse to obtain?

• A. current blood sugar level
• B. degree of paresthesia in feet
• C. wound healing of knee abrasion
• D. A1c glycosylated hemoglobin

Correct answer: B

Rationale: Assessing for paresthesia (numbness or tingling) in the feet is crucial in this scenario as it can help determine if the client has a loss of sensation, which increases the risk of falls. Paresthesia is a common complication of diabetes that can lead to decreased sensation and proprioception in the feet, contributing to balance issues and an increased risk of falls. Monitoring for paresthesia allows the nurse to assess the extent of sensory impairment and implement appropriate interventions to prevent future falls. While monitoring blood sugar levels (choice A) and A1c levels (choice D) are important in managing diabetes, in this case, assessing paresthesia takes precedence due to its direct impact on fall risk. Similarly, while monitoring the wound healing of the knee abrasion (choice C) is important for overall wound care, it is not directly related to reducing the risk of future falls in this situation.

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