Nursing Elites

1. A 30-year-old woman is experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?

• A. Initiate cardiopulmonary resuscitation
• B. Check for a pulse
• C. Ask the woman if she carries an emergency medical kit
• D. Stay with the woman until help comes

Correct answer: C

Rationale: In a situation where a patient is experiencing anaphylaxis, it is crucial to act swiftly. Asking the woman if she carries an emergency medical kit is the most appropriate initial intervention. Many individuals with a history of anaphylaxis carry epinephrine auto-injectors, such as epi-pens, which can be life-saving in such situations. Initiating cardiopulmonary resuscitation (CPR) is not indicated as the patient is breathing but short of breath, and CPR is not the first-line intervention for anaphylaxis. Checking for a pulse, though important, is not the initial priority in managing anaphylaxis. Staying with the woman until help arrives is essential for providing support and monitoring her condition, but confirming the availability of an emergency medical kit takes precedence to promptly address the anaphylactic reaction.

2. A nurse and client are discussing the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?

• A. Pre-interaction
• B. Orientation
• C. Working
• D. Termination

Correct answer: C

Rationale: The correct answer is the working phase. During this phase, the nurse and client actively work together to explore alternative behaviors and techniques. Discussions in this phase focus on understanding the underlying meaning behind the behavior and implementing strategies for change. Pre-interaction (choice A) refers to the phase before the nurse and client first meet and establish a relationship. The orientation phase (choice B) involves introductions, setting goals, and establishing boundaries. Termination (choice D) is the phase where the therapeutic relationship concludes, and closure is achieved.

3. Which client is at highest risk for developing a pressure ulcer?

• A. 23 year-old in traction for fractured femur
• B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
• C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
• D. 30 year-old who is comatose following a ruptured aneurysm

Correct answer: C

Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

4. The nurse is discussing negativism with the parents of a 30-month-old child. How should the nurse advise the parents to best respond to this behavior?

• A. Reprimand the child and give a 15-minute 'time out'
• B. Maintain a permissive attitude for this behavior
• C. Use patience and a sense of humor to deal with this behavior
• D. Assert authority over the child through limit setting

Correct answer: C

Rationale: Use patience and a sense of humor to deal with this behavior. The nurse should help the parents understand that negativism is a normal part of a toddler's growth towards autonomy. Reacting with patience and humor can help diffuse the situation and maintain a positive relationship with the child. Reprimanding the child and giving a 'time out' (Choice A) may not be effective for addressing negativism and can lead to power struggles. Maintaining a permissive attitude (Choice B) may reinforce negative behavior. Asserting authority through limit setting (Choice D) may be necessary in some situations, but using patience and humor is a more effective initial approach for handling negativism.

5. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

• A. The tumor is less than 3 cm in size and requires no chemotherapy.
• B. The tumor did not extend beyond the kidney and was completely resected.
• C. The tumor extended beyond the kidney but was completely resected.
• D. The tumor has spread into the abdominal cavity and cannot be resected.

Correct answer: C

Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed. Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor. Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected. Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.

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