Nursing Elites

1. While walking to the mailbox, an older adult male experiences sudden chest tightness and drives himself to the emergency department. When the client gets up to the desk of the triage nurse, he says his heart is pounding out of his chest as he clutches his chest and falls to the floor. Which intervention should the nurse implement first?

• A. Prepare for cardiac defibrillation.
• B. Apply cardiac monitor leads.
• C. Obtain troponin serum levels.
• D. Palpate the client’s artery.

Correct answer: D

Rationale: Palpating the client's artery is the priority intervention in this scenario because it helps determine if there is a pulse, which is crucial information in emergency situations like this. If the client is pulseless, immediate initiation of CPR is necessary. Applying cardiac monitor leads or obtaining troponin serum levels can wait until the presence of a pulse is confirmed. Cardiac defibrillation is not indicated without first assessing the client's pulse and cardiac rhythm.

2. What are the clinical manifestations of otitis media?

• A. Earache, wheezing, vomiting
• B. Coughing, rhinorrhea, headache
• C. Fever, irritability, pulling on ear
• D. Wheezing, cough, drainage in ear canal

Correct answer: C

Rationale: The correct answer is C: Fever, irritability, pulling on the ear. Clinical manifestations of otitis media commonly include fever, irritability, and children may show signs of pulling or rubbing their ears. Choices A, B, and D are incorrect. Choice A includes wheezing and vomiting, which are not typical symptoms of otitis media. Choice B includes coughing, rhinorrhea, and headache, which are more commonly associated with upper respiratory infections rather than otitis media. Choice D includes wheezing, cough, and drainage in the ear canal, which are not typical clinical manifestations of otitis media.

3. Which is a priority nursing intervention for the cognitively impaired child?

• A. The family will provide good nutrition.
• B. The family will provide loving interactions.
• C. Stimulation will improve.
• D. There will be contact with peers.

Correct answer: B

Rationale: The correct answer is B because nursing interventions for cognitively impaired children prioritize promoting loving interactions with family. This support helps in creating a nurturing environment that contributes to the child's well-being and development. Choice A is not the priority as good nutrition, though important, may not address the immediate emotional and social needs of the child. Choice C is vague and does not specify how stimulation will be provided. Choice D, contact with peers, is also valuable but not as crucial as the primary relationships and interactions within the family unit for a cognitively impaired child.

4. What is the most common clinical manifestation of coarctation of the aorta?

• A. Clubbing of the digits
• B. Upper extremity hypertension
• C. Pedal edema and portal congestion
• D. Loud systolic ejection murmur

Correct answer: B

Rationale: The correct answer is B: Upper extremity hypertension. Coarctation of the aorta leads to increased blood pressure in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs. Choice A, clubbing of the digits, is not a common clinical manifestation of coarctation of the aorta. Choice C, pedal edema, and portal congestion are more suggestive of conditions like heart failure rather than coarctation of the aorta. Choice D, loud systolic ejection murmur, can be heard in conditions like aortic stenosis, but it is not the most common clinical manifestation of coarctation of the aorta.

5. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

• A. Collect a urine specimen for culture analysis
• B. Review the client's fluid intake prior to bedtime
• C. Palpate the bladder above the symphysis pubis
• D. Obtain a fingerstick glucose level

Correct answer: C

Rationale: Palpating the bladder above the symphysis pubis is the most appropriate intervention in this scenario. It helps assess for urinary retention, which is a common issue in older males presenting with symptoms like difficulty starting urinary stream and feeling of incomplete bladder emptying. Collecting a urine specimen for culture analysis (Choice A) may be necessary in other situations like suspected urinary tract infection. Reviewing the client's fluid intake (Choice B) is important but does not directly address the current issue of urinary retention. Obtaining a fingerstick glucose level (Choice D) is not relevant to the client's urinary symptoms.

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