Nursing Elites

1. In which part of the plan of care should a nurse record the item 'Encourage patient to attend one psychoeducational group daily'?

• A. Assessment
• B. Analysis
• C. Planning
• D. Implementation

Correct answer: D

Rationale: The correct answer is 'Implementation.' In the nursing process, implementation involves carrying out the planned interventions to meet the patient's goals. Encouraging the patient to attend a psychoeducational group daily is an intervention aimed at building social skills. Assessment (choice A) is the phase where data about the patient's condition is collected. Analysis (choice B) involves interpreting the gathered data. Planning (choice C) is where the nurse decides on the interventions to address the patient's needs. Therefore, in this scenario, recording the item 'Encourage patient to attend one psychoeducational group daily' would be part of the implementation phase.

2. A mother brings her child to the well-child clinic and expresses concern to the nurse because the child has been playing with another child diagnosed with hepatitis. The nurse prepares to perform an assessment on the child, knowing that which finding would be of least concern for hepatitis?

• A. Jaundice
• B. Hepatomegaly
• C. Dark-colored, frothy urine
• D. Left upper abdominal quadrant pain

Correct answer: D

Rationale: Assessment findings in a child with hepatitis typically include right upper quadrant tenderness and hepatomegaly. The child may also present with pale, clay-colored stools and dark, frothy urine. Jaundice, which can be observed in the sclerae, nail beds, and mucous membranes, is a common sign of hepatitis. Left upper abdominal quadrant pain is not a typical finding associated with hepatitis; therefore, it would be of least concern in this scenario. The other options are more commonly associated with hepatitis and are important signs to monitor for in a child with possible exposure to the virus.

3. A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient?

• A. The patient is allergic to shellfish.
• B. The patient has a pacemaker.
• C. The patient suffers from claustrophobia.
• D. The patient takes antipsychotic medication.

Correct answer: B

Rationale: The correct answer is that the patient has a pacemaker. A pacemaker is a contraindication to MRI scanning due to the interference with the magnetic fields of the MRI scanner. This interference can potentially deactivate the pacemaker, putting the patient at risk. Patients with cardiac implantable electronic devices (CIED) are at risk for inappropriate device therapy, device heating/movement, and arrhythmia during MRI. This necessitates special precautions such as scheduling in a CIED blocked slot or having electrophysiology nurse or technician support. It is important to ensure that the patient's pacemaker is MRI conditional before proceeding with the scan. The other choices, such as being allergic to shellfish, suffering from claustrophobia, or taking antipsychotic medication, are not direct contraindications to undergoing an MRI scan for suspected lung cancer.

4. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is 615 pg/ml. What would the healthcare provider take as the priority action?

• A. Call for a cardiac evaluation and implement appropriate measures
• B. Check the patient's oxygen saturation
• C. Inform the physician about the elevated BNP level
• D. Encourage the patient to limit physical activity

Correct answer: B

Rationale: An elevated BNP level is indicative of decreased cardiac output, suggesting potential heart failure. In this scenario, the priority action is to check the patient's oxygen saturation. Oxygen saturation assessment is crucial to ensure adequate oxygenation and respiratory function, which is essential in managing cardiac conditions. Calling for a cardiac evaluation and implementing appropriate measures may be necessary but is not the immediate priority without assessing oxygen saturation. Informing the physician about the elevated BNP level can be important for further management but is not the immediate action needed in this situation. Encouraging the patient to limit physical activity might be a consideration later but is not the priority action when dealing with a potential cardiac emergency.

5. When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

• A. assess for the presence of chest pain.
• B. inquire about urinary tract problems.
• C. inspect the skin for rashes or discoloration.
• D. ask the patient about any increase in libido.

Correct answer: B

Rationale: When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.

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