Nursing Elites

1. During a petit mal seizure in the clinic, what should be the highest priority?

• A. Provide a safe environment free of obstructions in the immediate area
• B. Call a code
• C. Contact the patient's physician
• D. Prevent excessive movement of the extremities

Correct answer: A

Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient's physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.

2. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

• A. within normal limits, so a weight-reduction diet is unnecessary
• B. lower than normal, so education about nutrient-dense foods is needed
• C. indicating obesity because the BMI is 35
• D. indicating overweight status because the BMI is 27

Correct answer: C

Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Choices A, B, and D are incorrect because the client's BMI is above 30, which falls under the obesity category. Therefore, a weight-reduction diet and increased physical activity are necessary to address the client's weight status and promote overall health.

3. A client begins a regimen of chemotherapy. Her platelet count falls to 98,000. Which action is least likely to increase the risk of hemorrhage?

• A. Test all excreta for occult blood.
• B. Use a soft toothbrush or foam cleaner for oral hygiene.
• C. Implement reverse isolation.
• D. Avoid IM injections.

Correct answer: C

Rationale: The correct answer is to implement reverse isolation. Reverse isolation is a protective measure used to protect patients from infections, not to affect the risk of hemorrhage. Testing all excreta for occult blood (Choice A) is important to monitor for signs of internal bleeding. Using a soft toothbrush or foam cleaner for oral hygiene (Choice B) is recommended to prevent gum bleeding. Avoiding IM injections (Choice D) is crucial to reduce the risk of bleeding in a client with a low platelet count. Therefore, among the given options, implementing reverse isolation is the least likely to increase the risk of hemorrhage.

4. A mother brings her 13-month-old child with Down Syndrome to a pediatric clinic reporting muscle weakness and poor movement. The child's reflexes are noted to be diminished. Which action should the nurse take first?

• A. Contact the physician immediately
• B. Have the patient go for an X-ray for a c-spine work-up
• C. Start an IV on the patient
• D. Position the child's neck in a neutral position

Correct answer: D

Rationale: In a child with Down Syndrome presenting with muscle weakness and diminished reflexes, an atlanto-axial dislocation is a concern. The priority action is to position the child's neck in a neutral c-spine posture to prevent further injury. This should be done before any movement or manipulation. Contacting the physician should follow to ensure appropriate evaluation and management. Initiating an IV is not indicated unless specifically ordered for a medical reason. Ordering an X-ray for a c-spine work-up should not be the first action as it may involve movement that could exacerbate the condition if an injury is present.

5. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?

• A. Dizziness and orthostatic hypotension.
• B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
• C. Drowsiness, lethargy, and fatigue.
• D. Neuropathy and tingling in the extremities.

Correct answer: B

Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.

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