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. Which of the following needs immediate medical attention and emergency intervention? The client who:

• A. complains of sharp pain upon taking a deep breath and excessive coughing.
• B. exhibits yellow, productive sputum, low-grade fever, and crackles.
• C. has a shift of the trachea to the left, with no breath sounds on the right.
• D. has asthma and complains of an inability to catch her breath after exercise.

Correct answer: C

Rationale: Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention. Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention. Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening. Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature. Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.

3. The nurse is caring for a client with hyperemesis gravidarum. What is the most likely electrolyte imbalance?

• A. Hypocalcemia
• B. Hypomagnesemia
• C. Hyponatremia
• D. Hypokalemia

Correct answer: D

Rationale: In hyperemesis gravidarum, where the client experiences severe nausea and vomiting, the most likely electrolyte imbalance is hypokalemia. Potassium is abundant in the stomach, and excessive vomiting leads to potassium loss. Hypocalcemia (Choice A) is not typically associated with hyperemesis gravidarum. Hypomagnesemia (Choice B) and Hyponatremia (Choice C) are less likely to occur compared to hypokalemia in this condition.

4. A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP"?nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?

• A. Cushingoid appearance
• B. Alopecia
• C. Temporary or permanent sterility
• D. Pathologic fractures

Correct answer: B

Rationale: The correct answer is B: alopecia. Chemotherapy drugs like vincristine and nitrogen mustard commonly cause hair loss (alopecia), which can significantly impact body image. While a Cushingoid appearance can be a side effect of long-term steroid use, it is not typically associated with the chemotherapy regimen mentioned. Temporary or permanent sterility can result from chemotherapy, affecting fertility but not directly contributing to altered body image. Pathologic fractures are not commonly linked to Hodgkin's disease or its treatment, unlike alopecia which is a well-known side effect.

5. A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?

• A. Aspiration noted on a honey-thick diet
• B. Pain felt during a bowel movement
• C. Pain felt in the left upper quadrant
• D. Right shoulder pain

Correct answer: B

Rationale: The correct answer is 'Pain felt during a bowel movement.' Endoscopy is used to examine the upper gastrointestinal tract, which includes the esophagus, stomach, and duodenum. Pain during a bowel movement would suggest an issue in the lower gastrointestinal tract, which is typically examined with a colonoscopy. Choices A, C, and D are not probable reasons for an endoscopy procedure as they relate to symptoms in the upper gastrointestinal tract or are not specific to gastrointestinal issues. Aspiration noted on a honey-thick diet could indicate a risk of aspiration pneumonia related to swallowing difficulties, which can be assessed through an endoscopy. Pain felt in the left upper quadrant may be related to conditions like gastritis or peptic ulcers that can be investigated using an endoscopy. Right shoulder pain can be a referred pain from conditions like gallbladder disease that can also be evaluated with an endoscopy.

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