Nursing Elites

1. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.

2. A client with a history of seizures is prescribed phenytoin. Which instruction should the nurse include in the discharge teaching?

• A. Report any signs of a sore throat or fever immediately
• B. Take the medication with antacids to reduce stomach upset
• C. Discontinue the medication if you feel drowsy
• D. Increase the dosage if you experience an aura

Correct answer: A

Rationale: The correct answer is A: 'Report any signs of a sore throat or fever immediately.' Phenytoin can cause blood dyscrasias, which can manifest as a sore throat or fever. These symptoms could indicate a serious side effect that requires immediate medical attention. Choice B is incorrect because phenytoin should not be taken with antacids as they can decrease its absorption. Choice C is incorrect because discontinuing phenytoin abruptly can lead to rebound seizures; drowsiness is a common side effect that may improve with time. Choice D is incorrect because adjusting the dosage of phenytoin should only be done under healthcare provider supervision, not based on experiencing an aura.

3. What could suddenly occur in a child with acute epiglottitis?

• A. Increased carbon dioxide levels
• B. Airway obstruction
• C. Inability to swallow
• D. Bronchial collapse

Correct answer: B

Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.

4. Which individual has the highest risk for developing skin cancer?

• A. A 16-year-old dark-skinned female who tans in tanning beds once a week.
• B. A 65-year-old fair-skinned male who is a construction worker
• C. A 25-year-old dark-skinned male whose mother had skin cancer.
• D. A 70-year-old fair-skinned female who works as a secretary.

Correct answer: B

Rationale: The correct answer is B, a 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals are at higher risk of developing skin cancer due to prolonged sun exposure. Construction workers are often exposed to the sun for long periods, further increasing the risk. Choices A, C, and D are less likely to develop skin cancer compared to choice B due to factors such as age, frequency of tanning bed use, and occupation.

5. A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question?

• A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
• B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
• C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
• D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.

Correct answer: D

Rationale: With a CD4+ T cell count of 200 cells/microliter, the client's immune system is severely compromised, leading to opportunistic infections.

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