Nursing Elites

1. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

• A. It is okay to not want to touch the burned areas of your body.
• B. Cosmetic surgery should be performed within the next year to be effective.
• C. Reconstructive surgery can completely restore your previous appearance.
• D. It could be helpful for you to attend a support group for people who have burn injuries.

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.

2. What dietary recommendations should be provided to a patient with GERD?

• A. Avoid mint and spicy foods
• B. Eat large meals before bed
• C. Consume liquids with meals
• D. Avoid foods high in potassium

Correct answer: A

Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. These types of foods can trigger acid reflux and worsen GERD symptoms. Choice B is incorrect as eating large meals before bed can increase the likelihood of acid reflux due to increased pressure on the lower esophageal sphincter. Choice C is also incorrect as consuming liquids with meals can cause distension in the stomach, potentially leading to reflux. Choice D is not directly related to GERD, as foods high in potassium are generally healthy and not specifically problematic for GERD patients.

3. What is the priority nursing intervention for a patient admitted with possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Obtain cardiac enzymes
• C. Get IV access
• D. Auscultate heart sounds

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This intervention is a priority for a patient with possible acute coronary syndrome because nitroglycerin helps vasodilate coronary arteries, increase blood flow to the heart muscle, relieve chest pain, and reduce cardiac workload. Obtaining cardiac enzymes (choice B) is important for diagnosing myocardial infarction but is not the initial priority. Getting IV access (choice C) is essential for medication administration and fluid resuscitation but is not the priority over administering nitroglycerin. Auscultating heart sounds (choice D) is a routine assessment but does not address the immediate need to relieve chest pain and improve blood flow to the heart in acute coronary syndrome.

4. What is the initial nursing action for a patient with a chest tube found to have an air leak?

• A. Check the tube connections
• B. Replace the chest tube
• C. Remove and reinsert the chest tube
• D. Document the incident

Correct answer: A

Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.

5. What are the manifestations of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe nausea and vomiting
• C. Elevated blood pressure and bradycardia
• D. Decreased heart rate and altered pupil response

Correct answer: A

Rationale: The correct manifestations of increased intracranial pressure (IICP) include restlessness, confusion, and irritability. These symptoms are a result of the brain being under pressure inside the skull. Severe nausea and vomiting (Choice B) are more commonly associated with increased intracranial pressure in children. Elevated blood pressure and bradycardia (Choice C) are not typical manifestations of increased intracranial pressure; instead, hypertension and bradycardia may be seen in Cushing's reflex, which is a late sign of increased IICP. Decreased heart rate and altered pupil response (Choice D) are also not primary manifestations of increased intracranial pressure, although altered pupil response, like a non-reactive or dilated pupil, can be seen in some cases.

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