Nursing Elites

1. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?

• A. Every 2 months
• B. Every 4 months
• C. Every 6 months
• D. Every 8 months

Correct answer: C

Rationale: Children with ADHD who are on long-term medication therapy should be assessed for side effects every 6 months. This timeframe allows healthcare providers to monitor the effects of the medication and make any necessary adjustments. Checking every 2 months (Choice A) may be too frequent and not practical for routine monitoring, while checking every 4 or 8 months (Choices B and D) may lead to missing potential side effects or delays in addressing them.

2. A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes an NG tube to be inserted and placed on intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?

• A. Soak the NG tube in warm water
• B. Insert the tube with the client's head tilted back
• C. Apply suction while inserting the tube
• D. Elevate the head of the bed 60 to 90 degrees

Correct answer: D

Rationale: Elevating the head of the bed 60 to 90 degrees is the correct intervention to facilitate proper placement of the NG tube. This position helps to use gravity to guide the tube smoothly into the gastrointestinal tract. Soaking the NG tube in warm water (Choice A) is not necessary for proper placement. Inserting the tube with the client's head tilted back (Choice B) can cause discomfort and may lead to improper placement. Applying suction while inserting the tube (Choice C) is not recommended as it can cause trauma to the nasal passages and esophagus.

3. When performing an assessment of a child with recurrent abdominal pain (RAP), what symptom is the child most likely to experience?

• A. Increased temperature
• B. Constipation
• C. Right quadrant pain
• D. Exercise-associated pain

Correct answer: B

Rationale: When assessing a child with recurrent abdominal pain (RAP), constipation is a common symptom. Children with RAP often experience periumbilical pain that is unrelated to eating, defecation, or exercise. While increased temperature, right quadrant pain, and exercise-associated pain can occur in various conditions, they are not typically associated with RAP in children.

4. Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?

• A. Potential for injury related to vertigo.
• B. Alteration in comfort due to ear pain.
• C. Impaired skin integrity due to immobility.
• D. Anxiety due to fear of falling.

Correct answer: A

Rationale: The correct answer is A. When caring for a client with Meniere’s disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere’s disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.

5. A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?

• A. Apical pulse 58 bpm.
• B. Core body temperature 100.8°F.
• C. Tachypnea with dyspnea.
• D. Multiple bruises over the chest area.

Correct answer: C

Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.

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