Nursing Elites

1. A high school nurse observes a 14-year-old female rubbing her scalp excessively in the gym. What is the most appropriate course of action for the nurse?

• A. Request the female’s parents for a private evaluation of her scalp
• B. Contact the female’s parents regarding the observations
• C. Observe the hairline and scalp for possible signs of lice
• D. Inform the student’s physician about the situation

Correct answer: C

Rationale: The most appropriate course of action for the nurse is to observe the hairline and scalp for possible signs of lice. The student's behavior of excessively rubbing her scalp raises concerns about a potential infestation, making it necessary to look for signs firsthand. Contacting the parents or the physician should be considered after observing for signs of lice to provide more information and take appropriate action. Requesting a private evaluation from the parents may not be required initially, as lice infestation is a common concern among children and observing for signs is the immediate step to address the situation.

2. In the Emergency Department (ED), which client should the nurse see first?

• A. COPD client with a non-productive cough
• B. Diabetic client who has an infected sore on the foot
• C. Client with adrenal insufficiency who feels weak
• D. Client with a fracture of the forearm in an air splint

Correct answer: C

Rationale: In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis. Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening. Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency. Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.

3. While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?

• A. Hypoglycemic patient
• B. Hyperglycemic patient
• C. Cardiac arrest
• D. End-stage renal failure

Correct answer: B

Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.

4. The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:

• A. use cold applications to the sprain during the first 24-48 hours.
• B. expect disability to decrease within the first 24 hours of injury
• C. expect pain to decrease within 3 hours after injury.
• D. begin progressive passive and active range of motion exercises immediately.

Correct answer: A

Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.

5. A nurse is caring for a patient in the step-down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?

• A. Bradycardia
• B. Increased pupil size bilaterally
• C. Change in LOC
• D. Vomiting

Correct answer: B

Rationale: The correct answer is 'Increased pupil size bilaterally.' When assessing for signs of increased intracranial pressure, bilateral pupil dilation is not typically associated with this condition. Instead, unilateral pupil changes, especially one pupil becoming dilated or non-reactive while the other remains normal, are indicative of increased ICP. Bradycardia, a change in level of consciousness (LOC), and vomiting are commonly seen in patients with increased intracranial pressure due to the brain's response to the rising pressure. Therefore, the presence of bilateral pupil dilation goes against the typical pattern observed in patients with increased intracranial pressure.

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