Nursing Elites

1. A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?

• A. Lethargy
• B. Agitation
• C. Ataxia
• D. Hearing loss

Correct answer: A

Rationale: Lethargy is a critical finding that requires the nurse's immediate attention when a client with a recent skull fracture is readmitted to the hospital. It can indicate increased intracranial pressure or other serious complications such as hemorrhage or infection. Addressing lethargy promptly is crucial to prevent further deterioration. Agitation, ataxia, and hearing loss are important to assess but do not signify the same level of urgency as lethargy in this context.

2. The home health nursing director is conducting an educational program for registered nurses and practical nurses about Medicare reimbursement. To obtain payment for Medicare services, what must be included in the client's record?

• A. A prescription from the healthcare provider for each visit made.
• B. Documentation of a skilled care service provided during the visit.
• C. A copy of the client's health history and social security card.
• D. A record of the preventative healthcare services provided during the visit.

Correct answer: B

Rationale: The correct answer is B: Documentation of skilled care services is required for Medicare reimbursement. Medicare reimbursement is based on the provision of skilled care services, not on prescriptions or preventative healthcare services. Including a copy of the client's health history and social security card is not a requirement for Medicare reimbursement.

3. The family health care plan includes the following listed in sequence:

• A. objective, statement of the problem, intervention, and evaluation
• B. objectives, intervention, evaluation, and statement of the problem
• C. evaluation, statement of the problems, objectives, and interventions
• D. statement of the problems, objectives, intervention, and evaluation

Correct answer: D

Rationale: In a family health care plan, the correct sequence should start with identifying the problems (statement of the problems), setting objectives, planning interventions, and then evaluating the outcomes. This sequence ensures a logical and structured approach to healthcare planning. Choices A, B, and C are incorrect as they do not follow the logical order of healthcare planning steps.

4. A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?

• A. Measles-mumps-rubella.
• B. Hepatitis B.
• C. Human papillomavirus.
• D. Pneumococcal.

Correct answer: B

Rationale: The correct answer is B: Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women as it helps prevent transmission of the virus to the baby during childbirth. Measles-mumps-rubella vaccine (choice A) is not directly related to the current situation of the client being pregnant. Human papillomavirus vaccine (choice C) is recommended for adolescents but is not specifically indicated in this case. Pneumococcal vaccine (choice D) is not a priority in this scenario compared to Hepatitis B, which is crucial for preventing vertical transmission.

5. The nurse is caring for an acutely ill 10-year-old client. Which of the following assessments would require the nurse's immediate attention?

• A. Rapid bounding pulse
• B. Temperature of 38.5 degrees Celsius
• C. Profuse diaphoresis
• D. Slow, irregular respirations

Correct answer: D

Rationale: The correct answer is D, slow, irregular respirations. In an acutely ill child, this assessment can indicate impending respiratory failure or neurological compromise, necessitating immediate intervention. Rapid bounding pulse (choice A) may indicate tachycardia but is not as immediately concerning as compromised respirations. A temperature of 38.5 degrees Celsius (choice B) is elevated but may not be the most urgent concern unless accompanied by other symptoms. Profuse diaphoresis (choice C) can indicate increased sympathetic activity but is not as critical as respiratory compromise.

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