Nursing Elites

1. Prior to leaving on a backpacking trip to Southeast Asia, a college student has received a tetanus booster shot. This immunization confers protection by way of what immune process?

• A. Passive natural immunity
• B. Active natural immunity
• C. Passive artificial immunity
• D. Active artificial immunity

Correct answer: D

Rationale: The correct answer is D: Active artificial immunity. A tetanus booster shot confers protection through active artificial immunity. Active immunity involves the body producing its antibodies in response to an antigen, providing long-lasting protection. In this case, the tetanus booster shot triggers the student's immune system to produce specific antibodies against tetanus toxins. Choices A, B, and C are incorrect because passive immunity does not involve the individual's immune system producing antibodies; instead, it involves the direct transfer of antibodies from another source (natural or artificial) for immediate, but temporary, protection.

2. During a flu shot clinic, one of the questions the student nurse asks relates to whether the client has a history of Guillain-Barré syndrome. The client asks, 'What is that?' How should the nursing student reply?

• A. A type of paralysis that affects movement on both sides of the body. It may even involve the respiratory muscles.
• B. Swelling of your arm where you got your flu shot and maybe your eyes and lips had some swelling as well.
• C. A degenerative disease where you have trouble walking without the help of a cane or walker.
• D. Influenza-like illness where you had fever and chills for 2 to 3 days after your last flu shot.

Correct answer: A

Rationale: The correct answer is A because Guillain-Barré syndrome is an acute immune-mediated polyneuropathy that can lead to paralysis affecting movement on both sides of the body, and in severe cases, involving the respiratory muscles. Choice B is incorrect as it describes local swelling, not the systemic effects of Guillain-Barré syndrome. Choice C is incorrect as it describes a degenerative disease affecting mobility, not an acute immune-mediated condition like Guillain-Barré syndrome. Choice D is incorrect as it describes flu-like symptoms following a flu shot, which is not the same as Guillain-Barré syndrome.

3. What is the best method to identify which type of stroke the client has?

• A. Obtain a 12-lead electrocardiogram STAT
• B. Obtain a blood specimen for electrolytes and blood cultures
• C. Ask the client about current allergies
• D. Obtain a cranial computerized tomogram (CT) STAT

Correct answer: D

Rationale: The correct answer is to obtain a cranial computerized tomogram (CT) STAT. A cranial CT scan is the best method to quickly identify the type of stroke a client is experiencing. Options A, B, and C are not appropriate for identifying the type of stroke as they are not specific to assessing stroke types.

4. What aspect of hormonal contraceptives places a woman at the greatest risk for the development of blood clots?

• A. Hormonal contraceptives increase serum triglyceride and cholesterol levels.
• B. Hormonal contraceptives increase platelet levels.
• C. Hormonal contraceptives increase blood levels of clotting factors.
• D. Hormonal contraceptives cause injury to blood vessel linings.

Correct answer: C

Rationale: The correct answer is C. Hormonal contraceptives increase blood levels of clotting factors, particularly factors II, VII, IX, and X. This elevation in clotting factors can predispose individuals to thromboembolic events, including blood clots. Choices A, B, and D are incorrect because hormonal contraceptives do not have a significant effect on serum triglycerides and cholesterol, platelet levels, or causing direct injury to blood vessel linings as the primary mechanism for clot formation.

5. During a home visit to a family of three: a mother, father, and their child, the mother tells the community nurse that the father (who is not present) had hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere so her husband won’t get angry and refuse treatment. Which of the following is the best response of the nurse?

• A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening.
• B. The nurse commends the mother’s efforts and agrees to let her handle things.
• C. The nurse commends the mother’s efforts and also contacts protective services.
• D. The nurse confronts the mother’s failure to protect the child.

Correct answer: C

Rationale: In this situation, the best response for the nurse is to commend the mother's efforts in seeking help for her husband by encouraging him to attend Alcoholics Anonymous. However, it is crucial for the nurse to also contact protective services to ensure the safety and well-being of the child. Option A is incorrect as it is not appropriate to condition non-interference on the husband attending a meeting that evening. Option B is incorrect because solely letting the mother handle things might put the child at risk. Option D is incorrect as it does not address the immediate need to ensure the child's safety through involving protective services.

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