Nursing Elites

1. A nurse is covering a pediatric unit and is responsible for a 15-year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls."? The most appropriate course of action for the nurse is to respond by stating:

• A. "I will talk to the doctor about it."?
• B. "Has this been going on for a while?"?
• C. "How do you know this?"?
• D. "Teenagers often exhibit signs of sexual interest in females."?

Correct answer: D

Rationale: The most appropriate response for the nurse in this situation is to acknowledge that teenagers often exhibit signs of sexual interest in females. This response normalizes the mother's concern and provides reassurance that such behavior is typical during adolescence. Option A deflects the conversation to the doctor without addressing the mother's concern directly. Option B focuses on the duration rather than addressing the mother's statement. Option C may come off as defensive or dismissive, questioning the mother's observation. Therefore, the best response is to acknowledge the normalcy of teenage behavior regarding sexual interest.

2. When auscultating breath sounds, the nurse auscultates over the following locations:

• A. Trachea and lateral areas of thoracic cage
• B. Anterior and posterior aspects of all lung fields
• C. The mid section as well as the lateral section of the lungs
• D. The mid-clavicular to mid-axillary lines comparing side to side

Correct answer: B

Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.

3. The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?

• A. Client with irritable bowel syndrome
• B. Family history of colon polyps
• C. Client with cirrhosis of the liver
• D. History of colon surgery

Correct answer: B

Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.

4. The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority?

• A. Continue to monitor urine output
• B. Check a pulse
• C. Check a blood pressure
• D. Check level of consciousness (LOC)

Correct answer: C

Rationale: The correct answer is to check a blood pressure. Diabetes insipidus can lead to dehydration and potential hypovolemic shock due to excessive urine output. Monitoring blood pressure is crucial to assess the client's circulatory status and detect signs of shock early. Checking the blood pressure will provide essential information on perfusion, which is vital in this situation. Continuing to monitor urine output, checking a pulse, or assessing the level of consciousness are important but not as high a priority as evaluating the blood pressure in a potentially critical situation like suspected diabetes insipidus.

5. One week ago, a client was involved in a motor vehicle crash (MVC) and was brought to the Emergency Department (ED). In the emergency department, the client received two stitches to the forehead and was sent home. Today, the client's spouse notes that the client 'acts like he is drunk' and cannot control his right foot and arm. The nurse will suspect?

• A. Meningitis
• B. Absence seizure
• C. Subdural hematoma
• D. Meniere's disease

Correct answer: C

Rationale: Yes! The nurse will suspect a subdural hematoma. In this case, the client's presentation of acting intoxicated and experiencing loss of motor control in the right foot and arm is indicative of an acute subdural hematoma. This condition can occur after a head injury with a slow venous bleed, where symptoms may not show until compensation mechanisms are overwhelmed. Meningitis (choice A) usually presents with fever, headache, and neck stiffness. Absence seizure (choice B) is characterized by brief periods of unconsciousness without convulsions. Meniere's disease (choice D) manifests with symptoms like vertigo, hearing loss, and tinnitus, which do not match the client's current symptoms.

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