Nursing Elites

1. A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there have been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine?

• A. Presence of associated manifestations.
• B. Location of the pain
• C. Pain quality
• D. Aggravating and relieving factors

Correct answer: A

Rationale: The nurse is identifying associated manifestations like nausea and vomiting that may occur with the pain. The presence of associated manifestations helps in understanding the broader clinical picture and potential causes of the pain. Location refers to where the pain is felt, pain quality describes the nature of the pain, and aggravating and relieving factors relate to what makes the pain worse or better. In this scenario, the focus is on identifying additional symptoms that can provide important diagnostic clues.

2. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?

• A. You should report this to the supervisor
• B. It is very upsetting to see an adult client regress
• C. Diapers are the best solution
• D. The client’s condition is not your concern

Correct answer: B

Rationale: The correct response is 'It is very upsetting to see an adult client regress.' In this situation, the nurse should acknowledge the emotional impact of caregiving on the assistive personnel and address it professionally. Choice A is incorrect because reporting to the supervisor may not directly address the emotional concerns raised. Choice C is incorrect because immediately resorting to diapers without further assessment or intervention is not the most appropriate solution. Choice D is incorrect as the client's well-being and care are a shared responsibility among healthcare team members.

3. A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?

• A. Ask the teenager to wait until a parent or legal guardian can be contacted
• B. Withhold treatment until telephone consent can be obtained from the partner
• C. Refer the teenager to a community pediatric hospital emergency department
• D. Proceed with the triage process in the same manner as any adult client

Correct answer: D

Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.

4. A healthcare professional is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the healthcare professional initiate?

• A. Contact
• B. Droplet
• C. Airborne
• D. Protective

Correct answer: B

Rationale: The correct answer is B: Droplet. Droplet precautions are required for infections that spread via droplets larger than 5 microns in diameter, such as pharyngeal diphtheria. Contact precautions are used for diseases that spread by direct or indirect contact. Airborne precautions are for diseases that spread through small particles in the air. Protective precautions are not a standard precautionary measure for specific infections like pharyngeal diphtheria.

5. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

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