Nursing Elites

1. You have accompanied the physician into the family waiting room to tell a young husband that his wife has not survived the car accident she was in. The husband is crying and distraught. What is the most appropriate approach to supporting this family member?

• A. Ask if he would like to donate his wife's organs
• B. Sit quietly with him
• C. Ask about funeral arrangements
• D. Consult social services

Correct answer: B

Rationale: The most caring and supportive approach in a time of extreme distress is usually to sit quietly with the distressed individual until they have had the opportunity to absorb the news and gather themselves. Providing a supportive presence is often the most valuable tool a caregiver can use when circumstances bring overwhelming emotional pain to those they are caring for. Asking about organ donation at this moment may come off as insensitive and should not be a priority. Inquiring about funeral arrangements and consulting social services can be addressed later, once the husband has had time to process the initial shock and emotions.

2. A client is brought into the emergency department after finishing a course of antibiotics for a urinary tract infection. The client is experiencing dyspnea, chest tightness, and agitation. Her blood pressure is 88/58, she has generalized hives over her body, and her lips and tongue are swollen. After the nurse calls for help, what is the next appropriate action?

• A. Start an IV and administer a 1-liter bolus of Lactated Ringer's solution
• B. Administer 0.3 mg of 1:1000 epinephrine IM
• C. Administer 15 mg diphenhydramine IM
• D. Monitor the client until help arrives

Correct answer: B

Rationale: A client experiencing an anaphylactic reaction will likely present with rash or hives, swelling of the lips, face, or tongue, hypotension, or dyspnea. In this scenario, the client is showing signs of anaphylaxis with dyspnea, chest tightness, hives, hypotension, and swelling of the lips and tongue. The next appropriate action would be to administer 0.3 mg of 1:1000 epinephrine intramuscularly. Epinephrine helps relax the muscles of the airway, improve breathing, and increase oxygenation, which is crucial in managing anaphylaxis. Starting an IV and administering fluids can be important but not the immediate priority. Diphenhydramine may be used as an adjunct therapy but should not delay the administration of epinephrine in the acute phase of anaphylaxis. Monitoring the client without providing immediate treatment can lead to a worsening of the anaphylactic reaction, potentially resulting in a life-threatening situation.

3. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?

• A. INR is 3 seconds long
• B. Heart rate is 110 beats per minute
• C. Intracranial Pressure is 22 mmHg
• D. Blood pressure is 140/80

Correct answer: C

Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.

4. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?

• A. Polyuria
• B. Weight gain
• C. Hypotension
• D. Grossly bloody urine

Correct answer: B

Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.

5. After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?

• A. Urinary incontinence
• B. Impaired tissue integrity
• C. Inability to suck and swallow
• D. Lack of knowledge about the disease (parents)

Correct answer: B

Rationale: In bladder exstrophy, the bladder is exposed and external to the body, leading to impaired tissue integrity related to the exposed bladder mucosa as the priority problem. Urinary incontinence is not a concern as the infant is not yet toilet trained. Inability to suck and swallow is unrelated to the disorder. While educating the parents about the condition is important, it is not the priority over addressing the immediate risk of impaired tissue integrity in the infant.

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