Nursing Elites

1. The healthcare provider is assessing a client with a suspected myocardial infarction. Which finding requires immediate intervention?

• A. Chest pain radiating to the left arm.
• B. Shortness of breath.
• C. Nausea and vomiting.
• D. Diaphoresis.

Correct answer: B

Rationale: Shortness of breath is a critical sign that can indicate heart failure or pulmonary edema, conditions that require immediate intervention in a client with a suspected myocardial infarction. Chest pain radiating to the left arm is a classic symptom of a myocardial infarction but may not necessitate immediate intervention compared to severe shortness of breath. Nausea and vomiting can be present in myocardial infarction but are not as urgent as shortness of breath. Diaphoresis, or sweating, is a common symptom of a myocardial infarction but may not be as immediately concerning as significant shortness of breath.

2. After assessing the health care needs of an elementary school, the nurse determines that an increased prevalence of pediculosis capitis is a priority problem. The nurse develops a 2-month program with the goal to eradicate the condition in the school. The program includes educational pamphlets sent home to parents and regular assessment of children by the school nurse. What action should the nurse implement to evaluate the effectiveness of the program?

• A. evaluate the teachers' ability to identify pediculosis capitis 2 months after initiation of the program
• B. conduct an initial examination of each child in the school to obtain baseline data
• C. survey parents 3 weeks after pamphlets are sent home to assess their understanding of the condition
• D. measure the prevalence of pediculosis capitis among the children after four months

Correct answer: D

Rationale: Measuring the prevalence of pediculosis capitis among the children after four months is the most appropriate action to evaluate the program's effectiveness. This approach provides data on the program's long-term impact and effectiveness in eradicating the condition. Option A focuses on the teachers' ability, which is not directly related to the program's effectiveness in eradicating the condition. Option B suggests conducting an initial examination, which does not provide information on the program's impact. Option C involves assessing parents' understanding, which is important but does not directly evaluate the program's effectiveness in eradicating pediculosis capitis.

3. A client with a history of coronary artery disease is admitted with chest pain. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Blood pressure of 130/80 mm Hg.
• C. Respiratory rate of 20 breaths per minute.
• D. Chest pain radiating to the left arm.

Correct answer: D

Rationale: The correct answer is D. Chest pain radiating to the left arm can be a sign of myocardial infarction (heart attack) and requires immediate intervention. This symptom is known as a classic presentation of a heart attack and warrants urgent medical attention to prevent further cardiac damage. Choices A, B, and C are not directly indicative of an acute cardiac event and may not require immediate intervention in this scenario. While heart rate, blood pressure, and respiratory rate are important vital signs to monitor, they do not specifically indicate the urgency associated with chest pain radiating to the left arm in a patient with a history of coronary artery disease.

4. The school nurse is developing an individualized healthcare plan for a student with type 1 diabetes. Which component is most important to include in the plan?

• A. a schedule for blood glucose monitoring
• B. a list of low-carbohydrate snacks
• C. a contact list of healthcare providers
• D. a log for recording insulin administration

Correct answer: A

Rationale: The correct answer is A: a schedule for blood glucose monitoring. Regular blood glucose monitoring is essential in managing type 1 diabetes as it helps in monitoring blood sugar levels, adjusting treatment plans, and preventing complications such as hypoglycemia or hyperglycemia. Choice B, a list of low-carbohydrate snacks, while important for managing blood sugar levels, is not as critical as consistent blood glucose monitoring. Choice C, a contact list of healthcare providers, though important for emergency situations, is not the most crucial component in managing daily care. Choice D, a log for recording insulin administration, is valuable for tracking insulin doses but does not directly address the immediate need for monitoring blood glucose levels.

5. The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?

• A. Graves' disease.
• B. Cushing's syndrome.
• C. Addison's disease.
• D. Hypothyroidism.

Correct answer: A

Rationale: The correct answer is A, Graves' disease. The symptoms described in the client are classic manifestations of hyperthyroidism, which is commonly caused by Graves' disease, an autoimmune condition affecting the thyroid. Weight loss, racing heart rate, difficulty sleeping, moist skin with fine hair, prominent eyes, lid retraction, and a staring expression are all indicative of hyperthyroidism. Choice B, Cushing's syndrome, is characterized by weight gain, hypertension, and a rounded face due to excess cortisol. Choice C, Addison's disease, presents with symptoms such as weight loss, fatigue, and hyperpigmentation due to adrenal insufficiency. Choice D, hypothyroidism, typically features symptoms opposite to those described in the client, such as weight gain, bradycardia, and dry skin.

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