Nursing Elites

1. The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is

• A. Intravenous fluid infusion
• B. Level of consciousness
• C. Pulse and respirations
• D. Extremities for injuries

Correct answer: B

Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.

2. A community health action that focuses on reducing the frequency and severity of asthma in inner-city children by requiring a local incinerator to install particulate filters is an example of:

• A. downstream intervention
• B. risk management
• C. primary prevention
• D. upstream intervention

Correct answer: D

Rationale: The correct answer is D: upstream intervention. Upstream thinking addresses the root causes of health problems to create long-term solutions. In this scenario, requiring the incinerator to install particulate filters tackles the root cause of asthma triggers, which is pollution, rather than just managing the symptoms or risks associated with asthma. Choice A, downstream intervention, would focus more on treating asthma symptoms after they have already occurred rather than preventing them. Choice B, risk management, typically involves strategies to assess, control, or mitigate risks, which may not directly address the root cause. Choice C, primary prevention, usually refers to actions taken to prevent a disease or condition before it occurs, but in this case, the action is targeting the underlying cause rather than preventing asthma itself.

3. A client comes into the community health center upset and crying stating, “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?

• A. 'Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid).'
• B. 'This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline.'
• C. 'Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor.'
• D. 'You probably have had episodes of sweating, heart pounding, and headaches.'

Correct answer: A

Rationale: The correct initial response for the nurse to provide in this situation is to offer reassurance. Stating that 'Pheochromocytomas usually aren't cancerous (malignant)' helps to alleviate the client's anxiety and fear of having cancer. This response also establishes a foundation for further discussion about the condition, allowing the nurse to address the client's concerns and provide accurate information. Choice B is incorrect as it focuses solely on the diagnostic tests for pheochromocytoma but does not address the client's emotional distress. Choice C is incorrect as it discusses imaging modalities without directly addressing the client's concerns. Choice D is also incorrect as it assumes symptoms without first addressing the client's emotional state and fear of cancer.

4. The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by

• A. Inserting a fenestrated catheter with a whistle tip without suction
• B. Completing the suction pass in 30 seconds with a pressure of 150 mm Hg
• C. Hyperoxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass
• D. Minimizing the suction pass to 60 seconds while slowly rotating the lubricated catheter

Correct answer: C

Rationale: Hyperoxygenating the client before and after suctioning helps prevent hypoxia by ensuring adequate oxygen levels during the procedure, which briefly interrupts the client's normal breathing pattern. Choice A is incorrect because inserting a fenestrated catheter with a whistle tip without suction would not prevent hypoxia. Choice B is incorrect as completing the suction pass in 30 seconds with a pressure of 150 mm Hg may lead to hypoxia. Choice D is incorrect as minimizing the suction pass to 60 seconds may not provide enough time for effective suctioning and could lead to hypoxia.

5. Which of the following is the most effective way to prevent the spread of communicable diseases in a community?

• A. Regular health check-ups
• B. Isolation of infected individuals
• C. Immunization programs
• D. Public health education

Correct answer: C

Rationale: Immunization programs are the most effective way to prevent the spread of communicable diseases. Vaccinations help build immunity against specific diseases, reducing the likelihood of an outbreak. Regular health check-ups (Choice A) are important for individual health but do not directly prevent the spread of diseases on a community level. Isolation of infected individuals (Choice B) is a containment measure rather than prevention for the entire community. Public health education (Choice D) is valuable in raising awareness but may not be as effective as immunization programs in directly preventing the spread of communicable diseases.

Similar Questions