Nursing Elites

1. For a client with suspected appendicitis, in which quadrant should the nurse expect to find abdominal tenderness?

• A. upper right
• B. upper left
• C. lower right
• D. lower left

Correct answer: C

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area. Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases. Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.

2. 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.

3. A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?

• A. With a physical therapist treating the patient
• B. With a social worker planning for discharge
• C. With another nurse on duty to plan for break time
• D. In the hallway outside the patient's room

Correct answer: D

Rationale: The correct answer is 'In the hallway outside the patient's room.' Discussing client information in a public area like a hallway can potentially breach patient confidentiality as it increases the risk of unauthorized individuals overhearing sensitive information. Choices A, B, and C involve discussing client information with other healthcare professionals in appropriate settings, which are more likely to maintain patient confidentiality compared to discussing in a public space like a hallway. Option D is the correct choice because it highlights a scenario where patient information is at higher risk of exposure to unauthorized individuals, hence violating patient confidentiality.

4. The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. He asks to clarify what type of diet he is to follow. Which diet is best for clients with ulcerative colitis?

• A. High vitamin
• B. High calorie
• C. Low sugar
• D. Low fiber

Correct answer: D

Rationale: The correct answer is 'Low fiber.' Clients with ulcerative colitis should follow a low-residue diet, which means consuming low fiber to reduce the frequency and volume of stools, helping to alleviate symptoms such as abdominal pain and diarrhea. High fiber diets can worsen the condition by stimulating bowel movements. Choice A, 'High vitamin,' is incorrect as the focus is on fiber content rather than vitamins. Choice B, 'High calorie,' is not specifically recommended for ulcerative colitis and may not address the symptoms effectively. Choice C, 'Low sugar,' does not directly address the dietary needs of clients with ulcerative colitis as the issue is more related to fiber intake than sugar consumption.

5. A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?

• A. Check the patient's chest x-ray results.
• B. Retake vitals including blood pressure.
• C. Perform a neurological screening on the patient.
• D. Request the physician on-call to assess the patient.

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.

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