Nursing Elites

1. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
• B. The nurse noted unilateral breast enlargement.
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.

2. Performing and supervising therapeutic and preventive procedures that have been planned for a patient is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: C

Rationale: The correct answer is C: Implementation. Implementation in nursing care involves the actual performance and supervision of the planned therapeutic and preventive procedures for a patient. Evaluation (choice A) is the step where the effectiveness of the interventions is assessed. Planning (choice B) is the phase where the nursing care plan is developed based on the assessment. Assessment (choice D) is the initial step in the nursing process, involving data collection and analysis to determine the patient's needs.

3. The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?

• A. The islet cells in the pancreas stop producing insulin
• B. The client eats too many foods that are high in sugar
• C. The pituitary gland does not produce vasopressin
• D. The cells become resistant to the circulating insulin

Correct answer: D

Rationale: In Type 2 diabetes, the primary issue is insulin resistance, where cells do not respond effectively to insulin. Choice A is incorrect as in Type 1 diabetes the islet cells in the pancreas stop producing insulin. Choice B is incorrect as while excessive sugar intake can contribute to the development of Type 2 diabetes, it is not the primary cause. Choice C is incorrect as the pituitary gland's function is unrelated to the development of Type 2 diabetes.

4. Enteral feedings may be appropriate for patients with:

• A. Acute cholecystitis
• B. Hepatic encephalopathy
• C. Ulcerative colitis in remission
• D. Acute exacerbation of Crohn’s disease

Correct answer: D

Rationale: Enteral feedings are commonly used in patients with Crohn’s disease during acute exacerbations to provide adequate nutrition while resting the bowel. Acute cholecystitis, hepatic encephalopathy, and ulcerative colitis in remission wouldn't typically require enteral feedings as the primary nutritional support. Acute cholecystitis may necessitate fasting and intravenous fluids, hepatic encephalopathy may require dietary modifications but not enteral feedings, and patients with ulcerative colitis in remission usually have their nutritional needs met through a regular diet.

5. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nursing assistant aspirates and measures the amount of the gastric aspirate
• B. The nursing assistant elevates the head of the client’s bed 30 degrees
• C. The nursing assistant warms the formula to room temperature
• D. B, C

Correct answer: D

Rationale: Elevating the head of the bed to 30 degrees reduces the risk of aspiration by promoting proper digestion and preventing reflux. Warming the formula to room temperature is essential to prevent discomfort and complications. Aspirating and measuring the gastric aspirate is not a recommended nursing action for monitoring enteral feeding via a nasogastric tube, as it can introduce the risk of introducing contaminants into the feeding tube. Therefore, choices A and B are incorrect, making choice D the correct answer.

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