Nursing Elites

1. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

• A. Place a call to the client's healthcare provider for instructions
• B. Send him to the emergency room for evaluation
• C. Reassure the client's wife that the symptoms are transient
• D. Instruct the client's wife to call the doctor if his symptoms become worse

Correct answer: B

Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.

2. The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother?

• A. You should use an orthodontic nipple on the child's bottle.
• B. You need to use a plastic spoon to feed the child.
• C. You can allow the child to use a pacifier but only for 30 minutes at a time.
• D. You need to monitor the child's temperature for signs of infection using an oral thermometer.

Correct answer: A

Rationale: After a cleft palate repair, it is crucial to use an orthodontic nipple on the child's bottle to feed them appropriately. The mother should be instructed to give the child baby food or baby food mixed with water. It is important to avoid introducing straws, pacifiers, spoons, or fingers into the child's mouth for 7 to 10 days post-surgery to prevent complications. The use of a pacifier should be avoided for at least 2 weeks following the surgical repair to promote proper healing. Additionally, taking oral temperatures should be avoided, and alternative temperature monitoring methods should be utilized to reduce the risk of infection. Therefore, options B, C, and D are incorrect because they could potentially lead to complications or hinder the child's recovery after cleft palate repair.

3. A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

• A. Place the child in the nearest bed
• B. Administer IV medication to slow down the seizure
• C. Place a padded tongue blade in the child's mouth
• D. Remove the child's toys from the immediate area

Correct answer: D

Rationale: During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action. Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.

4. A healthcare professional is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?

• A. S. pneumoniae
• B. H. influenzae
• C. N. meningitidis
• D. Cl. difficile

Correct answer: D

Rationale: The correct answer is Cl. difficile. Clostridium difficile (C. diff) is not typically associated with meningitis in humans. This bacterium is known to cause severe diarrhea, usually as a result of antibiotic treatment. S. pneumoniae, H. influenzae, and N. meningitidis are all known to be causative agents of meningitis in humans. S. pneumoniae is a common cause of bacterial meningitis, especially in adults. H. influenzae, particularly type b (Hib), used to be a leading cause of meningitis in children before the introduction of the Hib vaccine. N. meningitidis is another significant pathogen responsible for causing meningitis, especially in young adults and adolescents.

5. An 85-year-old client is diagnosed with hypernatremia due to lack of fluid intake and dehydration. The nurse knows that symptoms of hypernatremia include:

• A. Lack of thirst
• B. Pale skin
• C. Hypertension
• D. Swollen tongue

Correct answer: D

Rationale: Hypernatremia among elderly clients can result from dehydration and insufficient fluid intake, leading to sodium levels above 145 mEq/L. Common symptoms of hypernatremia include mental status changes, a thick or swollen tongue, excessive thirst, and flushed skin. Choice A, 'Lack of thirst,' is incorrect as hypernatremia typically presents with excessive thirst. Choice B, 'Pale skin,' is not a typical symptom of hypernatremia. Choice C, 'Hypertension,' is not a direct symptom of hypernatremia and is more commonly associated with other conditions like hypertension itself.

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