Nursing Elites

1. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

• A. Nutrition
• B. Elimination
• C. Activity
• D. Safety

Correct answer: D

Rationale: In caring for a client with severe depression, safety is a critical priority. The nurse must address precautions to prevent suicide as part of the care plan. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the immediate risk of harm associated with depression. Ensuring the client's safety by implementing measures to prevent self-harm or suicide is the priority intervention. Addressing nutrition, elimination, and activity can follow once the client's safety is assured.

2. The clinic nurse reviews the record of an infant and notes that the primary healthcare provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek healthcare for the infant?

• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Foul-smelling, ribbon-like stools

Correct answer: D

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is a congenital anomaly characterized by an absence of ganglion cells in the rectum and other areas of the affected intestine. A key clinical manifestation of Hirschsprung's disease is chronic constipation that starts in the first month of life, leading to pellet-like or ribbon-like stools that have a foul smell. Another sign is the delayed passage or absence of meconium stool in the neonatal period. In addition to foul-smelling, ribbon-like stools, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive are also common clinical manifestations of this disorder. Options A, B, and C are not typically associated with Hirschsprung's disease, making them incorrect choices in this scenario.

3. The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?

• A. Offer psychological support for depression.
• B. Offer high-calorie, high-protein dietary choices.
• C. Administer prescribed opioids to relieve pain as needed.
• D. Teach about the need to avoid scratching any pruritic areas.

Correct answer: C

Rationale: The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.

4. A client with a new colostomy is being taught how to care for the colostomy bag. Which statement from the client indicates the need for more education?

• A. I can clean the skin around the ostomy site with soap and water when I change the bag.
• B. I should irrigate the stoma regularly to avoid buildup of gas and odor.
• C. I need to wait 30 minutes after I irrigate to replace the colostomy bag.
• D. I should change the bag when it is one-third to one-fourth full.

Correct answer: C

Rationale: A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions. Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.

5. A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the following laboratory tests assesses coagulation? Select one that doesn't apply.

• A. Partial thromboplastin time
• B. Prothrombin time
• C. Platelet count
• D. Hemoglobin

Correct answer: D

Rationale: The correct answer is 'Hemoglobin.' Hemoglobin levels are not indicative of coagulation status but are important for assessing oxygen-carrying capacity. Choices A, B, and C are all laboratory tests that assess coagulation. Partial thromboplastin time (PTT) and prothrombin time (PT) evaluate different aspects of the coagulation cascade, while platelet count is essential for assessing primary hemostasis. Therefore, in the context of evaluating coagulation, hemoglobin is not the appropriate choice.

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