Nursing Elites

1. A client with tuberculosis is receiving isoniazid (INH). The nurse should monitor the client for which of the following side effects?

• A. Hepatotoxicity
• B. Hyperglycemia
• C. Hypotension
• D. Hypokalemia

Correct answer: A

Rationale: The correct answer is A: Hepatotoxicity. Isoniazid (INH) can lead to hepatotoxicity, necessitating the monitoring of liver function tests. This adverse effect is characterized by liver damage and dysfunction. Choices B, C, and D are incorrect because isoniazid is not typically associated with hyperglycemia, hypotension, or hypokalemia. Therefore, the nurse should focus on assessing for signs and symptoms of hepatotoxicity in a client receiving isoniazid.

2. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to

• A. Give the client orientation materials and review the unit rules and regulations
• B. Introduce oneself and accompany the client to their room
• C. Take the client to the day room and introduce them to the other clients
• D. Ask the nursing assistant to get the client’s vital signs and complete the admission search

Correct answer: B

Rationale: In situations where a client is trembling and fearful upon admission to a psychiatric unit, it is essential to prioritize building trust and reducing anxiety. By introducing oneself and accompanying the client to their room, the nurse can establish a therapeutic relationship, provide a sense of security, and address the client's immediate emotional needs. Choices A, C, and D are not the most appropriate initial responses as they do not directly address the client's emotional state or focus on establishing a supportive relationship.

3. In planning the use of resources for secondary prevention in a community clinic serving migrant families, which activity should be the priority?

• A. Skin testing for tuberculosis.
• B. Glucose monitoring for diabetes.
• C. Blood work for cardiovascular disease.
• D. Height and weight for altered nutrition.

Correct answer: A

Rationale: The correct answer is A: Skin testing for tuberculosis. In a community clinic serving migrant families, tuberculosis is a significant health concern due to close living conditions and potential exposure during migration. Skin testing for tuberculosis is crucial for secondary prevention as it helps in early detection and prevention of the spread of the disease within the community. Choices B, C, and D are important health screenings but may not be the priority in this specific population where tuberculosis poses a higher risk.

4. You attended a home delivery with the Rural Health midwife. The newborn is premature. Which of the following should be included in premature infant care at home?

• A. establishing and maintaining good respiration
• B. proper management of feeding
• C. minimum handling of the baby
• D. regulation of body temperature

Correct answer: D

Rationale: Corrected Rationale: Regulation of body temperature is crucial for the survival of a premature infant. Premature infants have difficulty regulating their body temperature, making it essential to keep them warm. While establishing and maintaining good respiration and proper feeding management are important aspects of infant care, they are not as critical as regulating body temperature for premature infants. Additionally, while minimizing handling to reduce stress can be beneficial, it is not as vital as temperature regulation for premature infants.

5. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?

• A. Playing with toys in a backyard flower garden
• B. Eating small amounts of grass while playing 'farm'
• C. Playing with cars on the pavement near burning leaves
• D. Throwing a ball to a neighborhood child who has poison ivy

Correct answer: C

Rationale: The correct answer is C. Poison ivy can be contracted through smoke from burning plants, which can carry the urushiol oil that causes the rash. Playing near burning leaves would be the highest risk for exposure in this scenario. Choices A, B, and D do not involve direct contact with burning plants or leaves, making them lower-risk activities for exposure to poison ivy.

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