Nursing Elites

1. In which situation(s) can personal health information be disclosed?

• A. Compliance with legal proceedings
• B. For research purposes in limited circumstances
• C. To a family member or significant other in an emergency
• D. All of the above

Correct answer: D

Rationale: Personal health information can be disclosed in various situations. Compliance with legal proceedings allows for disclosure under specific legal requirements. Disclosure for research purposes is permitted in limited circumstances with appropriate approvals. In emergencies, information can be shared with family members or significant others. Therefore, all of the choices are correct as they represent valid scenarios for disclosing personal health information.

2. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

• A. Assess the client’s vital signs
• B. Start an IV with an 18-gauge needle
• C. Begin iced saline lavage
• D. A, B

Correct answer: D

Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client’s vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.

3. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

• A. Discontinue the heparin drip prior to initiating the Coumadin
• B. Check the client’s INR prior to beginning Coumadin
• C. Clarify the order with the health care provider as soon as possible
• D. Administer the Coumadin along with the heparin drip as ordered

Correct answer: D

Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.

4. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

• A. Preoccupation with calories
• B. Thick body hair
• C. Sore tongue
• D. Dry, brittle hair

Correct answer: D

Rationale: The correct answer is D: Dry, brittle hair. Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. Preoccupation with calories (choice A) is more related to the psychological aspect of anorexia rather than a physical finding. Thick body hair (choice B) is not typically associated with anorexia nervosa. A sore tongue (choice C) can be seen in conditions like vitamin deficiencies or oral health issues but is not specific to anorexia nervosa.

5. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?

• A. Instruct the client to avoid drinking fluids with meals
• B. Explain the need to decrease intake of flatus-forming foods
• C. Teach the client how to perform gentle perianal care
• D. Encourage the client to see a psychologist

Correct answer: B

Rationale: The correct answer is B. Decreasing the intake of flatus-forming foods can help reduce symptoms of bloating and discomfort in IBS. This intervention focuses on dietary modifications that can positively impact the client's condition. Instructing the client to avoid drinking fluids with meals (choice A) may not directly address the underlying cause of IBS symptoms. Teaching perianal care (choice C) is important for hygiene but does not directly address IBS symptoms. Encouraging the client to see a psychologist (choice D) may be beneficial for managing stress or anxiety associated with IBS but does not directly target symptom reduction through dietary changes.

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