Nursing Elites

1. A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?

• A. At the onset of menstruation
• B. Every month during ovulation
• C. Weekly, at the same time of day
• D. One week after menstruation begins

Correct answer: D

Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.

2. Which of these is not a symptom of Serotonin Syndrome?

• A. edema
• B. fever
• C. confusion
• D. tremors

Correct answer: A

Rationale: Serotonin syndrome, caused by an excess of serotonin, typically presents with symptoms such as altered mental status (confusion), neuromuscular abnormalities (tremors), and autonomic dysfunction (fever). Edema, which refers to swelling caused by fluid retention in the body tissues, is not a common symptom associated with serotonin syndrome. Therefore, the correct answer is 'edema.' Choice A, 'edema,' is the correct answer as it is not typically seen in serotonin syndrome. Choice B, 'fever,' is a symptom of serotonin syndrome, as it can cause autonomic dysfunction. Choice C, 'confusion,' is a common symptom due to altered mental status in serotonin syndrome. Choice D, 'tremors,' is also a common symptom due to neuromuscular abnormalities in serotonin syndrome.

3. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse makes which determination?

• A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
• B. The results are negative.
• C. The results indicate that the mother does not have hepatitis B
• D. The client needs to receive the hepatitis B series of vaccines.

Correct answer: A

Rationale: A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission. Therefore, choice A is correct. Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother. Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.

4. The LPN on shift notices a client coming into the clinic with bruises on his arm. The client seems very afraid and doesn't speak much, which concerns the nurse because these are signs of physical abuse. The nurse should ____.

• A. use therapeutic communication to talk to the client and offer support while reporting the findings to the appropriate authorities based on the state requirements and protocols
• B. report the findings to the appropriate authorities based on the state requirements and protocols
• C. ignore the bruises, as this is not why the client is being treated and is not appropriate for the nurse to address
• D. report the suspected abuse to another nurse and collaborate on how to handle it

Correct answer: B

Rationale: In cases of suspected abuse, healthcare providers have a legal and ethical obligation to report such incidents to the relevant authorities. This not only ensures the safety and well-being of the client but also helps in preventing further harm. Option A is incorrect as attempting to gather evidence of abuse may interfere with the official investigation and is not the nurse's role. Offering support is crucial, but the priority is to report the findings to the appropriate authorities. Option C is incorrect as ignoring signs of abuse goes against the duty of a healthcare provider to protect their clients. Option D is incorrect as reporting suspected abuse to other nurses without involving the appropriate authorities may delay necessary actions and intervention.

5. An LPN is tasked with checking the narcotic count on a medical-surgical unit. Which statement by the LPN requires further investigation?

• A. "I need a witness when I waste the leftover narcotics in the client's PCA pump."?
• B. "I am going to check the facility's policy for how to dispose of this controlled substance."?
• C. "I left the narcotics box unlocked after confirming the beginning of shift count was correct."?
• D. "The end of shift narcotics count is incorrect and needs to be reported."?

Correct answer: C

Rationale: The LPN's statement about leaving the narcotics box unlocked after confirming the beginning of shift count was correct requires further investigation. Narcotics should be locked and kept in a secure place during the shift to prevent unauthorized access and ensure patient safety. This statement raises concerns about medication security, which is critical in preventing diversion and ensuring patient safety. The other statements demonstrate appropriate actions: A) The LPN acknowledges the need for a witness when wasting leftover narcotics, ensuring proper documentation and accountability during medication waste. B) Checking the facility's policy for proper disposal of controlled substances shows awareness of regulatory compliance regarding controlled substances. D) Recognizing an incorrect end-of-shift narcotics count and planning to report it reflects the LPN's responsibility in maintaining accurate records and addressing discrepancies, which is essential for medication safety and accountability.

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