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. A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?

• A. Diarrhea and Vomiting
• B. Dizziness and Drowsiness
• C. Metallic taste
• D. Hypoglycemia

Correct answer: D

Rationale: The correct answer is 'Hypoglycemia.' When a patient is on NPO status (nothing by mouth) and prescribed metformin, there is an increased risk of hypoglycemia due to the absence of oral intake. Metformin, as an anti-glycemic drug, can lower blood sugar levels, and without food intake, the risk of hypoglycemia is higher. Diarrhea and vomiting are common gastrointestinal side effects of metformin but are not the main concern in this scenario. Dizziness and drowsiness are potential side effects of some medications but are not typically associated with metformin. Metallic taste is a known side effect of metformin but is not the primary concern in this situation where hypoglycemia is more critical to monitor due to the patient's NPO status.

3. After assessing Mr. B, what is the initial action of the nurse?

• A. Immediately place the client in a negative-pressure room
• B. Set the client up to receive a bronchoscopy
• C. Contact the physician for antifungal medications
• D. Administer oxygen and assist the client to sit in the semi-Fowler's position

Correct answer: A

Rationale: The first action the nurse should take after assessing Mr. B is to administer oxygen and assist him to sit in the semi-Fowler's position. Administering oxygen helps improve tissue oxygenation, while sitting up in a semi-Fowler's position aids in better breathing and secretion clearance. Placing the client in a negative-pressure room is not the immediate priority unless isolation is needed. Performing a bronchoscopy or contacting the physician for antifungal medications is not the initial step in managing a client with suspected pneumonia.

4. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, what would serologic testing most likely reveal?

• A. antibody to hepatitis D (anti-HDV).
• B. hepatitis B surface antigen (HBsAg).
• C. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
• D. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

Correct answer: D

Rationale: Hepatitis A is primarily transmitted through the oral-fecal route. During the acute phase of hepatitis A, serologic testing typically reveals anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). This antibody appears early in the course of the infection. The presence of anti-HAV IgM indicates an acute infection with hepatitis A. Choices A and B are incorrect as hepatitis D and hepatitis B antigens are not typically associated with acute hepatitis A. Choice C, anti-hepatitis A virus immunoglobulin G (anti-HAV IgG), would indicate a past infection and lifelong immunity, which is not expected during the acute phase of the illness.

5. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?

• A. Knife fight
• B. Auto accident
• C. Sunburn
• D. Fungal infection

Correct answer: C

Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.

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