Nursing Elites

1. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?

• A. Inflammation of the vessels
• B. Obstructed blood flow
• C. Overhydration
• D. Stress-related headaches

Correct answer: B

Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.

2. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?

• A. Apply a cool compress to the affected fingers for 20 minutes
• B. Secure a pulse oximeter to monitor the client's oxygen saturation
• C. Report the finding to the healthcare provider as soon as possible
• D. Continue to monitor the fingers until the color returns to normal

Correct answer: D

Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.

3. A client with hyperthyroidism is prescribed methimazole. Which adverse effect should the nurse monitor for?

• A. Agranulocytosis
• B. Hypoglycemia
• C. Bradycardia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is Agranulocytosis. Methimazole, used to treat hyperthyroidism, can lead to agranulocytosis, a severe decrease in white blood cells. This condition increases the risk of infections and requires immediate medical attention. Hypoglycemia (choice B) is not a common adverse effect of methimazole. Bradycardia (choice C) is unlikely as methimazole tends to have minimal effects on heart rate. Hypercalcemia (choice D) is not associated with methimazole use.

4. How should the nurse measure urinary output for an infant with dehydration?

• A. Attaching a urine collecting bag
• B. Wringing out the diaper
• C. Weighing the diaper
• D. Inserting a catheter

Correct answer: C

Rationale: The correct way to measure urinary output for an infant with dehydration is by weighing the diaper. Wet diapers are weighed to assess the amount of output accurately. Attaching a urine collecting bag and inserting a catheter are invasive methods not typically used for routine measurement of urinary output in infants. Wringing out the diaper can lead to inaccurate measurements and is not a recommended method for assessing urinary output.

5. When assessing an adolescent with depression, what is the most important question for the nurse to ask?

• A. What is causing your feelings of depression?
• B. Have you ever thought about suicide?
• C. What actions can we take to improve your mood?
• D. Would you like your friends to come over?

Correct answer: B

Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.

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