Nursing Elites

1. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?

• A. It is a problem-focused process of continued nursing care
• B. It is an open-ended process of continued nursing care
• C. It is a circular process of continued nursing care
• D. It is a trial-and-error process of continued nursing care

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation is a continuous and cyclical process in nursing care. Choice A is incorrect because the method is not solely problem-focused but involves multiple steps. Choice B is incorrect as it does not capture the structured nature of the four-step method. Choice D is incorrect as it implies a random approach rather than a systematic and organized process.

2. 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.

3. Which situations are classified as natural disasters?

• A. Blizzards
• B. A, C
• C. Volcanic eruptions
• D. Structural collapse

Correct answer: B

Rationale: The correct answer is B. Blizzards and volcanic eruptions are both examples of natural disasters caused by natural forces such as extreme weather conditions and tectonic activities. On the other hand, structural collapse is typically a result of man-made factors like poor construction or maintenance. Therefore, choices A, C, and D are incorrect as only blizzards and volcanic eruptions are classified as natural disasters.

4. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

• A. The client with three (3) unifocal PVCs in a minute
• B. The client diagnosed with coronary artery disease who wants to ambulate
• C. The client diagnosed with mitral valve prolapse with an audible S3
• D. The client diagnosed with pericarditis who is in normal sinus rhythm

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure, which requires immediate assessment. Choice A is less urgent as occasional unifocal PVCs are common. Choice B is important but can be addressed after the client with an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable compared to a client with potential heart failure symptoms.

5. Which endocrine disorder would the nurse assess for in a client who has a closed head injury with increased intracranial pressure?

• A. Pheochromocytoma
• B. Diabetes insipidus
• C. Hashimoto’s disease
• D. Gynecomastia

Correct answer: B

Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (choice A) is a tumor of the adrenal gland and is not directly related to closed head injury or increased intracranial pressure. Hashimoto’s disease (choice C) is an autoimmune disorder affecting the thyroid gland, not commonly associated with head injuries. Gynecomastia (choice D) is the development of breast tissue in males and is not an endocrine disorder typically linked to closed head injuries.

Similar Questions