Nursing Elites

1. The nurse is assisting with the triage of clients at a large community disaster and finds a man lying on the ground, who states that the blast threw him out of a second-story window. Which action should the nurse implement first?

• A. Logroll the client to his side and assess for back injuries
• B. Perform a complete neurological assessment
• C. Open the client's airway immediately
• D. Place the nurse's hands around the client's neck to stabilize

Correct answer: C

Rationale: Opening the client's airway immediately is the priority in this scenario. Ensuring the airway is clear takes precedence over other actions as it is crucial for the client's breathing and oxygenation. Logrolling the client to assess for back injuries may worsen the condition if there are spinal injuries, so this should not be done as the first step. Performing a complete neurological assessment is important but not the immediate priority over ensuring the airway is clear. Placing the nurse's hands around the client's neck to stabilize is incorrect and could potentially harm the client, as neck stabilization should only be done if there is a suspected neck injury, which is not indicated in this case.

2. In a community clinic where a recent case of tuberculosis (TB) has been diagnosed, which client who attended the clinic is at the highest risk for presenting with TB?

• A. a young adult who works as a daycare worker
• B. an adult who works in a corporate office
• C. an adolescent who attends the community high school
• D. an adult with a history of alcoholism and homelessness

Correct answer: D

Rationale: Individuals who are homeless and have a history of alcoholism are at the highest risk for presenting with TB in this scenario. Homeless individuals often live in crowded conditions with poor ventilation, increasing the likelihood of TB transmission. Additionally, alcoholism can weaken the immune system, making individuals more susceptible to developing TB. The other options, such as a daycare worker, an office worker, or a high school student, do not inherently carry the same level of risk factors for TB transmission as being homeless with a history of alcoholism.

3. The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?

• A. Lung sounds and respiratory status.
• B. Skin integrity and color.
• C. Neurological status and level of consciousness.
• D. Cardiac rate and rhythm.

Correct answer: D

Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.

4. When developing a presentation on injury prevention for high school students in a health education class, which topic is most important for the nurse to include?

• A. Sports-related injuries
• B. Substance abuse
• C. Seat belt safety
• D. Pregnancy prevention

Correct answer: C

Rationale: The correct answer is C: Seat belt safety. This topic is crucial as it can significantly reduce the risk of injury or death in car accidents, which is a common cause of severe injuries among high school students. While sports-related injuries, substance abuse, and pregnancy prevention are important topics, seat belt safety directly addresses a preventable cause of injuries that can have immediate life-saving effects.

5. A community health nurse is addressing the issue of elder abuse in the community. Which intervention should be prioritized?

• A. providing education on the signs of elder abuse
• B. setting up a support group for elder abuse survivors
• C. partnering with local law enforcement to increase patrols
• D. creating a confidential hotline for reporting abuse

Correct answer: D

Rationale: The prioritized intervention for addressing elder abuse in the community should be the creation of a confidential hotline for reporting abuse. A confidential hotline offers a safe and accessible way for individuals to report elder abuse and seek help promptly. Providing education on the signs of elder abuse (Choice A) is important but may not directly address immediate reporting and intervention needs. Setting up a support group for elder abuse survivors (Choice B) is beneficial for emotional support but may not address the primary need for reporting abuse. Partnering with local law enforcement to increase patrols (Choice C) focuses on prevention rather than providing a direct reporting mechanism for victims.

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