Nursing Elites

1. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?

• A. Introduce him- or herself
• B. Make the family comfortable
• C. Give assurance of privacy
• D. Explain the purpose of the interview

Correct answer: A

Rationale: Introducing oneself is the first step in establishing a rapport and setting a professional tone for the interaction.

2. Examination of the abdomen is performed correctly by the nurse in which order?

• A. Inspection, palpation, percussion, and auscultation
• B. Inspection, percussion, auscultation, and palpation
• C. Palpation, percussion, auscultation, and inspection
• D. Inspection, auscultation, percussion, and palpation

Correct answer: D

Rationale: The correct order for abdominal examination is inspection, auscult

3. The parents of an infant with a cleft palate ask the nurse, "What follow-up care will our infant need after the repair?" Which is an accurate response by the nurse?

• A. Your infant will not need any subsequent follow-up care
• B. Your infant will only need to be evaluated by an audiologist
• C. Your infant will only need follow-up with a speech pathologist
• D. Your infant will need follow-up with audiologists and orthodontists

Correct answer: D

Rationale: After cleft palate repair, the child will need ongoing follow-up with audiologists, speech pathologists, and orthodontists to monitor hearing, speech development, and dental alignment.

4. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?

• A. Place a warm moist pack on the scrotal area.
• B. Instruct the adolescent to lie down and elevate the legs.
• C. Refer the adolescent for immediate medical evaluation.
• D. Suggest that the adolescent wear a scrotum-protecting guard.

Correct answer: C

Rationale: Testicular torsion is a surgical emergency requiring immediate medical evaluation. Applying heat or elevating the legs will not alleviate the torsion, and delaying care can lead to testicular necrosis.

5. Melena, the passage of black, tarry stools, suggests bleeding from which source?

• A. The perianal or rectal area
• B. The upper gastrointestinal (GI) tract
• C. The lower GI tract
• D. Hemorrhoids or anal fissures

Correct answer: B

Rationale: Melena indicates bleeding from the upper GI tract. The black, tarry appearance of the stool results from the partial digestion of blood as it passes through the intestines, typically originating from sources like the stomach or duodenum. Lower GI bleeding usually presents as bright red blood in the stool, originating from sources like the colon or rectum. Choices A, C, and D are incorrect because melena specifically points to upper GI bleeding rather than issues in the perianal/rectal area, lower GI tract, or hemorrhoids/anal fissures.

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