Nursing Elites

1. When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?

• A. Allow her to grieve by herself.
• B. Tell her to go ahead and cry, after all, your husband’s pretty bad off.
• C. Tell her you realize how upset she is, but you don’t want to talk about it now.
• D. Approach her, offering tissues, and encourage her to verbalize her feelings

Correct answer: D

Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions. Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.

2. A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following?

• A. voiding patterns
• B. characteristics of lesions
• C. vaginal discharge
• D. prior history of varicella

Correct answer: D

Rationale: The correct answer is 'prior history of varicella.' When assessing a client with genital herpes, it is important to gather data on voiding patterns, characteristics of lesions, and vaginal discharge as these are pertinent to the disease. However, the prior history of varicella is not directly related to the current diagnosis of genital herpes. Varicella, which refers to chickenpox, is caused by the varicella-zoster virus, a different virus from the herpes simplex virus causing genital herpes.

3. A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?

• A. An 8-year-old boy has been vomiting, appears to have slower movements, and has a history of an atrioventricular shunt placement.
• B. A 10-year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.
• C. A 7-year-old boy has been having a low fever and headache for the past 3 days and has a history of an anterior knee wound.
• D. A 7-year-old girl who had a cast on her right ankle is complaining of itching.

Correct answer: A

Rationale: The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.

4. The chemotherapeutic agent 5-fluorouracil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true?

• A. It is a local treatment affecting only tumor cells.
• B. It is a systemic treatment affecting both tumor and normal cells.
• C. It has not yet been proven an effective treatment for cancer.
• D. It is often the drug of choice because it causes few, if any, side effects.

Correct answer: B

Rationale: The correct answer is that chemotherapy is a systemic treatment affecting both tumor and normal cells. 5-FU, as an antimetabolic drug, inhibits DNA synthesis and interferes with cell replication systemically. It affects all rapidly growing cells, including malignant and normal ones. This drug is used as adjuvant therapy for various cancers. Choice A is incorrect because chemotherapy affects both tumor and normal cells, not just tumor cells. Choice C is incorrect as chemotherapy has been proven effective in treating cancer. Choice D is incorrect because chemotherapy often causes side effects like bone marrow depression, anorexia, stomatitis, nausea, and vomiting.

5. When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?

• A. Allergies to shellfish
• B. Date of last platelet donation
• C. Time of last oral intake
• D. Blood type

Correct answer: B

Rationale: The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.

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