Nursing Elites

1. The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?

• A. Inability to touch their toes
• B. Asymmetry of the shoulders when standing upright
• C. Audible crepitus when bending
• D. An exaggerated upper thoracic convex curvature

Correct answer: B

Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.

2. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

• A. The client has asymmetrical chest wall expansion
• B. The client complains of pain at the insertion site
• C. The client's chest x-ray indicates decreased pleural effusion
• D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26

Correct answer: A

Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.

3. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates immediate intervention?

• A. The client complains of a throbbing headache rated 10 (on a scale of 1 to 10)
• B. The client repeatedly falls asleep while talking with the nurse
• C. The entry site has a slow trickle of bright red blood
• D. The entry site appears reddened and edematous

Correct answer: B

Rationale: In a client with a pellet gun injury and a comminuted skull fracture, repeatedly falling asleep while talking with the nurse is a concerning sign. It can indicate increased intracranial pressure or a deteriorating condition, requiring immediate intervention. The other options, such as a throbbing headache (choice A), slow trickle of bright red blood at the entry site (choice C), or reddened and edematous entry site (choice D), while important to monitor, do not directly indicate a need for immediate intervention as much as the client falling asleep repeatedly while talking does.

4. An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse?

• A. Reports a tearing, sharp pain between his shoulder blades
• B. Blood pressure reading of 200/100 mmHg 15 minutes later
• C. Rose-colored urine draining from the urinary catheter
• D. Sinus tachycardia with frequent premature ventricular beats (PVC)

Correct answer: A

Rationale: A tearing, sharp pain between the shoulder blades may indicate aortic dissection, a serious complication requiring immediate intervention. This symptom is highly concerning in a patient with a thoracic aneurysm. Choice B is not as urgent as the pain symptom described in choice A. Choice C could indicate hematuria but is not as critical as the potential aortic dissection in choice A. Choice D, sinus tachycardia with PVCs, may be related to the patient's condition but is not as indicative of an immediate life-threatening situation as the tearing, sharp pain indicative of aortic dissection.

5. After undergoing an uncomplicated gastric bypass surgery, a client is experiencing difficulty managing their diet. What dietary instruction is most important for the nurse to explain to the client?

• A. Chew food slowly and thoroughly before attempting to swallow
• B. Plan volume-controlled evenly spaced meals throughout the day
• C. Sip fluid slowly with each meal and between meals
• D. Eliminate or reduce intake of fatty and gas-forming foods

Correct answer: A

Rationale: The correct answer is A. Thoroughly chewing food is crucial for clients who have undergone gastric bypass surgery to aid in digestion and prevent complications. Proper chewing helps break down food into smaller particles, making it easier for the digestive system to process. This instruction is essential to prevent issues such as food blockages or inadequate nutrient absorption. Choices B and C are also important for post-gastric bypass clients to maintain proper nutrition and hydration, but they are not as critical as ensuring thorough chewing. Choice D addresses dietary concerns but is not as immediately crucial as ensuring the client chews food properly to support digestion and prevent complications.

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