Nursing Elites

1. A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.

• A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
• B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
• C. The client should lie flat on their back for a specific period following the procedure.
• D. The risks of the procedure include headache, back pain, and infection.

Correct answer: B

Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.

2. A teacher brings a 5-year-old child to the school nurse because of a bruise under her eye. When asked about the bruise, the child responds, 'my daddy did it.' What is the nurse's initial action in this situation?

• A. Allow the child to return to class and monitor for future events that are suggestive of abuse
• B. Call the parent and request an explanation for the bruises
• C. Call the police and ask for a warrant for the parent's arrest
• D. Notify the school administrator

Correct answer: D

Rationale: In cases of suspected child abuse, the priority for the school nurse is to notify the school administrator immediately. The school administrator can then collaborate with the nurse to follow established protocols for reporting suspected abuse to the appropriate authorities. All suspicions or allegations of child abuse must be handled with sensitivity and in compliance with state laws and school policies. All other options, such as allowing the child to return to class without further action, directly contacting the parent, or involving the police without proper investigation, could potentially compromise the safety and well-being of the child and may not adhere to legal requirements for reporting suspected abuse.

3. A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

• A. An adolescent male
• B. An elderly woman
• C. A young woman
• D. An elderly man

Correct answer: C

Rationale: The correct answer is 'A young woman.' Raynaud's disease is most common in young women and is often associated with rheumatologic disorders like lupus and rheumatoid arthritis. This disorder involves vasospasm of the arteries, leading to reduced blood flow to the fingers and toes. Typically, Raynaud's affects the fingers, and in some cases, it can affect the toes. Only rarely does it involve other body parts such as the nose, ears, nipples, and lips. Choices B, C, and D are less likely as Raynaud's disease predominantly affects young women, although it can occur in other demographic groups as well.

4. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

5. A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?

• A. Observation
• B. Reflection
• C. Summarizing
• D. Validating

Correct answer: B

Rationale: The nurse is demonstrating the therapeutic communication technique of reflection. In this scenario, the nurse is redirecting the question back to the client, encouraging them to explore their thoughts and feelings about the situation. Reflection involves restating a statement or question in a way that prompts the client to consider their own answers, fostering self-awareness and insight. Observation involves stating facts, summarizing involves condensing information, and validating involves confirming the client's feelings or experiences, none of which are demonstrated in this interaction.

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