Nursing Elites

1. A patient taking sildenafil (Viagra) asks a nurse what action to take if priapism occurs. Which response should the nurse provide?

• A. Take an additional half-strength dose of sildenafil
• B. The condition usually resolves in 12 hours or less
• C. Wait until the following day and notify the doctor
• D. Seek emergency help, because permanent damage can occur

Correct answer: D

Rationale: Patients experiencing priapism from sildenafil should seek immediate medical attention. Priapism is a serious condition where an erection lasts longer than 4 hours, and if left untreated, it can lead to irreversible damage to the penile tissue, potentially causing permanent erectile dysfunction. Therefore, prompt intervention is crucial to prevent long-term complications.

2. During a well-child visit, a nurse is assessing a three-year-old toddler. Which of the following manifestations should the nurse report to the provider?

• A. Blood pressure 90/50
• B. Respiratory rate 45/min
• C. Weight 14.5 kg or 32 lb
• D. Heart rate 110/min

Correct answer: B

Rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and may indicate respiratory dysfunction or acute respiratory distress. It is essential for the nurse to report this finding promptly to the healthcare provider for further evaluation and intervention.

3. A patient is prescribed fluconazole (Diflucan) for a vaginal yeast infection. The nurse should be concerned if the patient is also taking which medication?

• A. Losartan (Cozaar)
• B. Simvastatin (Zocor)
• C. Lisinopril (Zestril)
• D. Hydrochlorothiazide (HCTZ)

Correct answer: B

Rationale: When fluconazole is taken with statins like simvastatin, it can increase the levels of the statin in the blood, potentially leading to adverse effects such as muscle pain and weakness. Therefore, the nurse should be concerned if the patient is taking simvastatin along with fluconazole.

4. A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?

• A. Spinal cord injury
• B. Increased intracranial pressure
• C. Typical for sleep
• D. Improvement

Correct answer: B

Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.

5. Which principle does not follow neuromaturational theory?

• A. The sequence and rate of motor development are consistent among infants
• B. Movement emerges from an interaction and cooperation of many systems
• C. Movement progresses from primitive reflexes to voluntary control
• D. Low-level skills are prerequisites for certain high-level skills

Correct answer: B

Rationale: Neuromaturational theory emphasizes that motor development progresses in a predictable sequence and rate, starting from primitive reflexes to voluntary control. It also states that low-level skills are foundational for higher-level skills. However, the theory does not support the idea that movement solely emerges from an interaction and cooperation of many systems, as it focuses more on the hierarchical development of motor skills.

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