Nursing Elites

1. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

• A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
• B. Place the client into the bed and administer the ordered PRN analgesic
• C. Check the client for bladder distention and the client's urinary catheter for kinks
• D. Turn the television off and then assist client to use relaxation techniques

Correct answer: C

Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.

2. The appropriate order of steps in active management of the third stage of labor includes:

• A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to ensure the placenta is intact.
• B. Intravenous oxytocin, cord clamping and cutting, and fundal massage.
• C. Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage.
• D. Controlled cord traction, fundal massage, and oxytocin.

Correct answer: C

Rationale: The correct sequence of steps in active management of the third stage of labor includes intramuscular injection of oxytocin to prevent postpartum hemorrhage, controlled cord traction with counter traction to the uterus to facilitate placental delivery, and uterine massage to aid in uterine contraction and prevent excessive bleeding. Choice A is incorrect because ergometrine administration is not routinely recommended in active management. Choice B is incorrect as intravenous oxytocin is not the preferred route of administration. Choice D is incorrect as the order of steps is not accurate.

3. A client comes into the community health center upset and crying stating, “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?

• A. 'Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid).'
• B. 'This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline.'
• C. 'Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor.'
• D. 'You probably have had episodes of sweating, heart pounding, and headaches.'

Correct answer: A

Rationale: The correct initial response for the nurse to provide in this situation is to offer reassurance. Stating that 'Pheochromocytomas usually aren't cancerous (malignant)' helps to alleviate the client's anxiety and fear of having cancer. This response also establishes a foundation for further discussion about the condition, allowing the nurse to address the client's concerns and provide accurate information. Choice B is incorrect as it focuses solely on the diagnostic tests for pheochromocytoma but does not address the client's emotional distress. Choice C is incorrect as it discusses imaging modalities without directly addressing the client's concerns. Choice D is also incorrect as it assumes symptoms without first addressing the client's emotional state and fear of cancer.

4. The nurse is planning a nutrition class for a group of high school students emphasizing the goals for nutrition from Healthy People 2020. Which meal selection provides the best choices in meeting these goals?

• A. pasta with cheese sauce, garlic butter bread, and vegetable juice drink
• B. a 6-oz pork chop, creamed peas, cheese sauce on potatoes, coffee
• C. vegetable lasagna, lettuce salad, a whole wheat roll, 8 oz of 2% milk
• D. bacon, lettuce, tomato sandwich, whole grain chips, 8 oz. of whole milk

Correct answer: C

Rationale: The correct answer is C because vegetable lasagna, lettuce salad, and a whole wheat roll with 2% milk align with the nutrition goals of Healthy People 2020. These choices provide a balanced meal with vegetables, whole grains, and dairy, promoting a healthier dietary pattern. Choices A, B, and D do not offer as comprehensive a selection of food groups or as healthy options as choice C, making them less aligned with the nutrition goals of Healthy People 2020.

5. Which of the following activities is an example of tertiary prevention?

• A. Health education
• B. Regular exercise
• C. Screening tests
• D. Physical therapy

Correct answer: D

Rationale: The correct answer is D, physical therapy. Tertiary prevention focuses on rehabilitation and treatment to prevent complications from a disease or injury. Physical therapy falls under this category as it helps individuals recover and improve functionality after an illness or injury. Choices A, B, and C are not examples of tertiary prevention. Health education (choice A) is more aligned with primary prevention by promoting healthy behaviors to prevent disease onset. Regular exercise (choice B) can be categorized under both primary and secondary prevention as it aims to prevent disease development and detect conditions early. Screening tests (choice C) are part of secondary prevention as they aim to detect diseases at an early stage for prompt treatment.

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