Nursing Elites

1. While screening all children in the third grade for head lice, the school nurse observes that one girl has a brownish thickening on her neck. Which action should the nurse take in response to this finding?

• A. review the child's medical folder for a list of allergies
• B. instruct the child's parents to begin treatment
• C. advise the child's parents to obtain a medical evaluation of the child
• D. none of the above

Correct answer: C

Rationale: The correct action for the nurse to take is to advise the child's parents to obtain a medical evaluation of the child. This is important because a medical professional needs to properly diagnose and treat the brownish thickening observed on the child's neck. Reviewing the child's medical folder for allergies (Choice A) is not appropriate in this situation as it does not address the specific concern. Instructing the child's parents to begin treatment (Choice B) without a proper diagnosis can be harmful and ineffective. Choosing 'none of the above' (Choice D) is not the best option when a potential health issue is identified; seeking a medical evaluation is the most appropriate course of action.

2. The nurse is assessing a client with pneumonia. Which finding requires immediate intervention?

• A. Temperature of 99°F (37.2°C).
• B. Respiratory rate of 20 breaths per minute.
• C. Heart rate of 90 beats per minute.
• D. Fatigue.

Correct answer: C

Rationale: In a client with pneumonia, a heart rate of 90 beats per minute requires immediate intervention. Jugular vein distention indicates increased central venous pressure, suggesting possible complications like heart failure or fluid overload. Monitoring the heart rate closely and addressing any signs of heart failure promptly are crucial. A temperature of 99°F is within normal range and does not require immediate intervention. A respiratory rate of 20 breaths per minute is also normal. Fatigue is a common symptom in pneumonia but does not indicate an immediate need for intervention compared to the critical nature of jugular vein distention.

3. A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?

• A. Glasgow Coma Scale (GCS) score of 15.
• B. Pupils are equal and reactive to light.
• C. Client is drowsy but arousable.
• D. Client does not remember the events leading to the injury.

Correct answer: C

Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.

4. An older client requiring total care resides with a family consisting of two daughters who take shifts providing care around-the-clock. During a home visit, the daughters ask the nurse about resources that are available for client care while they attend a scheduled family reunion. Which information is best for the nurse to provide?

• A. propose the family seek assistance for care in the area of the reunion's location
• B. tell the caregivers to consider hiring a private duty nurse during the time away
• C. advise to have a case management evaluation of the client's home environment
• D. suggest social services be contacted to find a respite care facility for the client

Correct answer: D

Rationale: Respite care provides temporary relief for primary caregivers, allowing them to attend the reunion while ensuring the client is cared for.

5. A school nurse is developing a program to address bullying among students. Which component is most important to include?

• A. education on the effects of bullying
• B. training for teachers on how to handle bullying incidents
• C. a peer mentoring program
• D. a zero-tolerance policy for bullying

Correct answer: B

Rationale: Training for teachers is the most important component to include in addressing bullying among students. Teachers play a crucial role in identifying, intervening, and preventing bullying incidents. By providing teachers with training on how to handle bullying, they can effectively address such situations, support victims, and educate students on appropriate behavior. While education on the effects of bullying (Choice A) is important, teachers need practical skills to intervene. Peer mentoring programs (Choice C) and zero-tolerance policies (Choice D) are valuable but may not be as effective without teachers being equipped to address bullying incidents directly.

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