Nursing Elites

1. A nurse working in a pediatric clinic observes bruises on the body of a four-year-old boy. The parents report the boy fell while riding his bike. The bruises are located on his posterior chest wall and gluteal region. What should the nurse do?

• A. Suggest a script for counseling the family to the doctor on duty.
• B. Recommend a warm bath for the boy to decrease healing time.
• C. Notify the case manager in the clinic about possible child abuse concerns.
• D. Recommend ROM exercises to the patient's spine to decrease healing time.

Correct answer: C

Rationale: In this scenario, the nurse is observing bruises on a child's body that are located in areas not commonly associated with accidental injuries. Given the concerning nature of the bruising pattern and the inconsistent history provided by the parents, the nurse should suspect possible child abuse and take appropriate action by notifying the case manager in the clinic. The safety and well-being of the child should always be the top priority. Counseling for the family, warm baths, or recommending range of motion (ROM) exercises are not appropriate actions in this situation and may not address the underlying issue of potential child abuse.

2. The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:

• A. use cold applications to the sprain during the first 24-48 hours.
• B. expect disability to decrease within the first 24 hours of injury
• C. expect pain to decrease within 3 hours after injury.
• D. begin progressive passive and active range of motion exercises immediately.

Correct answer: A

Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.

3. Which of the following viruses is most likely to be acquired through casual contact with an infected individual?

• A. influenza virus
• B. herpes virus
• C. cytomegalovirus (CMV)
• D. human immunodeficiency virus (HIV)

Correct answer: A

Rationale: The correct answer is influenza virus. Influenza virus is most likely to be acquired through casual contact with an infected individual as it is transmitted through respiratory droplets. Herpes virus is primarily transmitted by direct contact, such as skin-to-skin contact, making it less likely to be acquired through casual contact. HIV is mainly transmitted through blood and body fluids like semen and vaginal fluids, not through casual contact. Cytomegalovirus (CMV) is an opportunistic infection commonly affecting immunocompromised individuals and is usually transmitted through close personal contact, not casual contact.

4. A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse anticipates that this client would be in which acid-base imbalance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The correct answer is respiratory alkalosis. Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. In this scenario, the client is extremely anxious and crying uncontrollably, indicating an increased respiratory rate and CO2 loss. Respiratory acidosis (choice A) is incorrect as it is characterized by an increase in CO2 levels, not a loss. Metabolic acidosis (choice C) involves a decrease in blood pH due to an accumulation of acids or loss of bicarbonate, which is not the case here. Metabolic alkalosis (choice D) results from excess bicarbonate or a loss of acids, not from increased CO2 loss due to hyperventilation.

5. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing is the property of another and must be treated with care.
• B. Such care facilitates repair and salvage of the clothing.
• C. The clothing of a trauma victim is potential evidence with legal implications.
• D. Such care decreases trauma to the family members receiving the clothing.

Correct answer: C

Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.

Similar Questions