Nursing Elites

1. A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?

• A. Heparin will dissolve clots that you have.
• B. Heparin will reduce the platelets that make your blood clot.
• C. Heparin will work better than warfarin.
• D. Heparin will prevent new clots from developing.

Correct answer: D

Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.

2. During your evaluation of a 14-year-old girl with a BMI of 18, she reports inability to eat, induced vomiting, and severe constipation. Which of the following would you most likely suspect?

• A. Multiple sclerosis
• B. Anorexia nervosa
• C. Bulimia nervosa
• D. Systemic sclerosis

Correct answer: B

Rationale: The clinical presentation described in the question is highly suggestive of anorexia nervosa. Anorexia nervosa is characterized by self-imposed starvation due to a distorted body image and an intense fear of gaining weight, even when the individual is underweight. The patient's symptoms of inability to eat, induced vomiting, and severe constipation align with the behavior seen in anorexia nervosa, including restrictive eating patterns and purging behaviors. Multiple sclerosis (Choice A) is a neurological disorder, not associated with the described symptoms. Bulimia nervosa (Choice C) typically involves binge eating followed by purging behaviors, which is different from the described primary restriction seen in anorexia nervosa. Systemic sclerosis (Choice D) is a connective tissue disorder and is not related to the symptoms of self-induced vomiting and severe constipation reported in this case.

3. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals

• A. HBsAg.
• B. anti-HBs
• C. anti-HBc IgG
• D. anti-HBc IgM.

Correct answer: B

Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection. Choices A, C, and D are incorrect because: A) HBsAg indicates current infection with hepatitis B virus, C) anti-HBc IgG suggests past infection or immunity, and D) anti-HBc IgM is a marker of acute hepatitis B infection.

4. The nurse is creating a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. What is the priority nursing intervention?

• A. Promoting bed rest
• B. Restricting oral fluids
• C. Allowing the child to play
• D. Encouraging visits from friends

Correct answer: A

Rationale: During the acute phase of glomerulonephritis, promoting bed rest is a priority to reduce stress on the kidneys and promote recovery. As the condition improves, activity can be gradually increased. Restricting oral fluids is not recommended as maintaining adequate hydration is crucial. Allowing the child to play quietly can be beneficial but is not the priority over rest during the acute phase. Encouraging visits from friends may disrupt the rest needed for recovery, so visitors should be limited.

5. The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

• A. The nail beds.
• B. The skin in the sacral area.
• C. The skin in the abdominal area.
• D. The membranes in the ear canal.

Correct answer: A

Rationale: Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.

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