Nursing Elites

1. An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?

• A. Does the child have any food allergies?
• B. What do the bowel movements look like?
• C. Has the child eaten any food in the last 24 hours?
• D. Can you describe the type of pain that the child is experiencing?

Correct answer: D

Rationale: The correct answer is asking the parents to describe the type of pain the child is experiencing because a report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. This specific question helps in identifying the key symptom of intussusception. Choices A, B, and C are important aspects of a health history but are not specific to the diagnosis of intussusception. Food allergies, bowel movements, and recent food intake are relevant for a comprehensive assessment but do not directly relate to the specific symptoms of intussusception.

2. After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

• A. Teach about drug-resistant TB treatment
• B. Ask the patient whether medications have been taken as directed
• C. Schedule the patient for directly observed therapy three times weekly
• D. Discuss with the healthcare provider the need for the patient to use an injectable antibiotic

Correct answer: B

Rationale: The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed. Teaching about drug-resistant TB treatment (Choice A) is premature without knowing the current medication compliance status. Scheduling directly observed therapy (Choice C) assumes non-compliance without confirming it first. Discussing the need for an injectable antibiotic (Choice D) is premature and not necessarily indicated without assessing the current medication adherence.

3. A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?

• A. Fear
• B. Helplessness
• C. Self-blame
• D. Rejection

Correct answer: C

Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.

4. Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

• A. Ask the patient to extend both arms forward.
• B. Request that the patient walk with eyes closed.
• C. Ask the patient to perform the Valsalva maneuver.
• D. Observe the patient's breathing pattern.

Correct answer: B

Rationale: To evaluate treatment effectiveness for a patient with hepatic encephalopathy, requesting the patient to walk with eyes closed is crucial. This test assesses the patient's balance, gait, and coordination, which can be impaired in hepatic encephalopathy due to altered mental status and brain function. Walking with eyes closed challenges the patient's sensory input and proprioception, providing valuable information on improvement or deterioration in neurological function. Asking the patient to extend both arms forward is used to check for asterixis, a sign often seen in hepatic encephalopathy, but it is not specific for evaluating treatment effectiveness. Performing the Valsalva maneuver is unrelated to assessing hepatic encephalopathy and is more commonly used in cardiac evaluations. Observing the patient's breathing pattern may be important in other conditions but is not directly relevant to evaluating treatment effectiveness for hepatic encephalopathy.

5. The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture?

• A. Learned through language acquisition and socialization.
• B. Genetically determined on the basis of racial background.
• C. A nonspecific phenomenon and is adaptive but unnecessary.
• D. Biologically determined on the basis of physical characteristics.

Correct answer: A

Rationale: Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It is not biologically or genetically determined, but rather acquired through social interactions. The correct answer, 'Learned through language acquisition and socialization,' aligns with the understanding that culture is a learned behavior. Choices B, C, and D are incorrect because culture is not genetically determined, nonspecific, or biologically based on physical characteristics. Understanding that culture is acquired through language and socialization is essential for healthcare providers to provide culturally competent care.

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