Nursing Elites

1. When assessing a geriatric patient who has possibly experienced an acute ischemic stroke, which of the following questions would be MOST appropriate to ask?

• A. When did you first notice the symptoms?
• B. Do you have a history of high blood pressure?
• C. What medications do you take and why?
• D. Have you previously had a heart attack?

Correct answer: A

Rationale: The most appropriate question to ask when assessing a geriatric patient who may have experienced an acute ischemic stroke is when the symptoms were first noticed. This information is crucial for determining the time window for potential treatments like thrombolytic therapy, as prompt intervention is necessary for stroke management. Option B is not as relevant in the acute assessment of stroke, though important for overall health history. Option C is important but may not be as time-sensitive as determining symptom onset. Option D focuses on a different cardiac event, not directly related to the current concern of a possible stroke.

2. What is the most appropriate technique to use when explaining a central line dressing change to a preschool-age client?

• A. Show a picture of the procedure in a book.
• B. Explain the procedure with clear instructions.
• C. Let the child perform a dressing change on a doll.
• D. None of the above.

Correct answer: C

Rationale: The most appropriate technique to use when explaining a central line dressing change to a preschool-age client is to let the child perform a dressing change on a doll. Preschool-age children learn best through play and hands-on activities. Allowing the child to practice on a doll helps them understand the procedure in a non-threatening and interactive way. This technique can reduce anxiety, increase cooperation, and enhance the child's understanding of the dressing change process. Choices A and B do not provide a hands-on approach, which is crucial for preschool-age children. Choice D is incorrect as providing an interactive experience is more effective than just showing pictures or giving verbal instructions.

3. Seizures in children MOST often result from:

• A. a life-threatening infection.
• B. an inflammatory process in the brain.
• C. an abrupt rise in body temperature.
• D. a temperature greater than 102°F.

Correct answer: C

Rationale: Seizures in children most often result from febrile seizures, which are triggered by an abrupt rise in body temperature. Febrile seizures are common in young children, especially between the ages of 6 months to 5 years, and are usually associated with viral infections that cause a sudden spike in body temperature. Choices A, B, and D are incorrect because while infections, inflammatory processes, and high temperatures can sometimes lead to seizures, the most common cause of seizures in children is an abrupt increase in body temperature, known as febrile seizures.

4. After the baby's head delivers, how is it usually tilted?

• A. with the face up.
• B. anteriorly, with the chin up.
• C. posteriorly, to one side.
• D. posteriorly, face down.

Correct answer: C

Rationale: After the baby's head delivers, it is typically tilted posteriorly to one side to help facilitate the delivery of the shoulders. This positioning is important for the safe and smooth delivery of the baby.

5. The client is being taught about perineal care postpartum. Which instruction should the client receive?

• A. Use ice packs to reduce swelling for the first 24 hours.
• B. Apply heat packs immediately after birth to reduce pain.
• C. Avoid using a peri-bottle to cleanse the perineum.
• D. Use tampons to absorb lochia discharge.

Correct answer: A

Rationale: The correct instruction for the client postpartum is to use ice packs to reduce swelling for the first 24 hours. This helps alleviate discomfort and promote healing. Applying heat packs immediately after birth is not recommended as they can increase swelling. A peri-bottle is advised for cleansing the perineum, not to be avoided. Tampons should not be used to absorb lochia discharge as they can increase the risk of infection. Therefore, the use of ice packs is the most appropriate and beneficial instruction for perineal care postpartum.

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