Nursing Elites

1. While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?

• A. Positive Homan's sign
• B. Fever and chills
• C. Dyspnea and cough
• D. Sensory impairment

Correct answer: C

Rationale: The correct answer is C: 'Dyspnea and cough.' Pulmonary embolism often presents with a sudden onset of dyspnea (difficulty breathing) and cough, which are due to the obstruction of blood flow in the pulmonary arteries. Choices A, B, and D are incorrect. Positive Homan's sign is associated with deep vein thrombosis, fever and chills are nonspecific symptoms commonly seen in infective endocarditis, and sensory impairment is not typically indicative of pulmonary embolism.

2. A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note

• A. High protein
• B. Clear color
• C. Elevated sed rate
• D. Increased glucose

Correct answer: A

Rationale: High protein levels in the cerebrospinal fluid are indicative of bacterial meningitis, as the presence of bacteria in the CSF leads to increased protein production. Elevated protein levels can be seen in inflammatory conditions like meningitis. Choice B, clear color, is not expected in meningitis as it is typically associated with cloudy or turbid CSF. Elevated sed rate (choice C) and increased glucose (choice D) are not typically associated with the laboratory findings seen in meningitis.

3. What is a critical factor in determining community health?

• A. Number of hospitals
• B. Availability of healthcare services
• C. Socioeconomic status
• D. Population density

Correct answer: B

Rationale: The availability of healthcare services is a critical factor in determining community health. While the number of hospitals may contribute to healthcare accessibility, it is the overall availability of healthcare services that encompasses various factors including hospitals, clinics, healthcare providers, and resources. Socioeconomic status and population density are important determinants of health outcomes, but the direct availability of healthcare services plays a more immediate and direct role in promoting community health.

4. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be

• A. Reduce fear and protect self-esteem
• B. Minimize anxiety and delay apprehension
• C. Avoid conflict and leave unpleasant situations
• D. Increase independence and communicate more effectively

Correct answer: A

Rationale: The correct answer is A: 'Reduce fear and protect self-esteem.' When teaching a client about the healthy use of ego defense mechanisms, the goal is to help the individual manage emotions effectively without denying reality. Using defense mechanisms in a healthy way aims to reduce fear and protect self-esteem while still addressing underlying issues. Choices B, C, and D are incorrect because they do not focus on the core principles of using defense mechanisms in a healthy manner. Minimizing anxiety and delaying apprehension, avoiding conflict and leaving unpleasant situations, and increasing independence and communicating more effectively do not directly align with the goal of utilizing ego defense mechanisms in a constructive way.

5. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?

• A. Arrange for a change in client care assignments
• B. Explain that this behavior is expected
• C. Discuss the appropriate use of 'time-out'
• D. Explain that the child is in need of extra attention

Correct answer: B

Rationale: The correct answer is to explain that this behavior is expected. At 16 months of age, children commonly experience separation anxiety, especially in unfamiliar environments like hospitals. It is important for the nurse to reassure the child and the parent that such behavior is normal. Option A is incorrect as there is no need to change client care assignments based on the child's behavior. Option C is not appropriate as discussing the use of 'time-out' is more relevant in behavior management for older children. Option D is incorrect as it does not address the underlying cause of the child's behavior related to separation anxiety.

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