Nursing Elites

1. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes
• B. The nurse noted unilateral breast enlargement
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

2. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

3. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?

• A. All below
• B. “My abdominal muscles may be tender because of the procedure.”
• C. “My diet should be light at first, and then I can progress to a regular diet.”
• D. “It is normal to feel gassy or bloated for a short while after the procedure.”

Correct answer: A

Rationale: Mild tenderness, a light diet initially, and gas or bloating are expected after a colonoscopy.

4. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)

• A. Obtain the pulses in all four extremities
• B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
• C. Determine the client’s orientation to person, place, and time
• D. B, C

Correct answer: D

Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.

5. What type of diet is recommended for patients with diverticulitis during an acute flare-up?

• A. High-fiber
• B. Low-residue
• C. Low-fat
• D. High-protein

Correct answer: B

Rationale: During an acute flare-up of diverticulitis, a low-residue diet is recommended. This diet helps reduce bowel movements and minimize irritation to the digestive tract, allowing the inflamed diverticula to heal. High-fiber foods are usually avoided during flare-ups as they can exacerbate symptoms. Low-fat and high-protein diets are not specifically recommended for diverticulitis flare-ups. Therefore, option B is the correct choice.

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