Nursing Elites

1. Which action should the school nurse take first when conducting a screening for scoliosis?

• A. Compare dorsal trunk measurements
• B. Have the individual extend arms over the head for visualization
• C. Inspect for symmetrical shoulder height
• D. Observe weight-bearing on each leg

Correct answer: C

Rationale: Inspecting for symmetrical shoulder height is a crucial initial step in screening for scoliosis. Asymmetry in shoulder height can indicate the presence of spinal curvature, which is a key indicator of scoliosis. This assessment is prioritized as it provides a visual clue to potential spinal abnormalities. Choices A, B, and D are not the first steps in scoliosis screening. Choice A involves a more detailed measurement that is not the primary visual indicator for scoliosis; choice B is not a primary indicator of scoliosis but can be used for further examination, and choice D is not directly related to identifying spinal curvature.

2. A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parent to assist in the diagnosis of cystic fibrosis (CF)?

• A. When you kiss her, does she taste salty?
• B. Do you notice if her urine has a musty odor?
• C. Has she been drinking cow's milk in her daily diet?
• D. How often does she have a normal bowel movement?

Correct answer: A

Rationale: The correct answer is A. Salty skin is a common sign of cystic fibrosis due to high levels of sodium in sweat. Asking about the taste of the child's skin provides valuable information related to the diagnosis of CF. Choices B, C, and D are not helpful in diagnosing cystic fibrosis. A musty odor in urine is not a typical symptom of CF. Drinking cow's milk or bowel movement frequency are not specific to CF diagnosis.

3. After a sudden loss of consciousness, a female client is taken to the ED, and initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that she was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan?

• A. Describe the importance of maintaining stable blood glucose levels.
• B. Encourage a balanced and nutritious diet.
• C. Reinforce the need to continue outpatient treatment.
• D. Educate on the risks of untreated anorexia nervosa.

Correct answer: C

Rationale: Continuing outpatient treatment is crucial for managing anorexia nervosa and preventing future complications. Reinforcing the need to continue outpatient treatment ensures ongoing support, monitoring, and therapy for the client's anorexia nervosa. Describing the importance of maintaining stable blood glucose levels (Choice A) is relevant but does not address the underlying eating disorder directly. Encouraging a balanced and nutritious diet (Choice B) is important; however, specific dietary recommendations should be tailored to the individual's condition by healthcare providers. Educating on the risks of untreated anorexia nervosa (Choice D) is informative but does not provide a direct actionable step for the client's immediate discharge plan, unlike the importance of continuing outpatient treatment.

4. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?

• A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.

5. Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?

• A. Prevent the spread of infection to others
• B. Improve the function of the immune system
• C. Increase the ability to carry out activities of daily living
• D. Promote a feeling of general well-being

Correct answer: B

Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.

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