Nursing Elites

1. A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?

• A. Spinal cord injury
• B. Increased intracranial pressure
• C. Typical for sleep
• D. Improvement

Correct answer: B

Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.

2. A teacher states to the school nurse, 'I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?' Which should the nurse include in the response to the teacher?

• A. The child has a crush on the teacher.
• B. The child has increased intracranial pressure.
• C. The child may have had a head injury.
• D. The child is experiencing absence seizures.

Correct answer: D

Rationale: Staring spells that end abruptly and are followed by normal activity are indicative of absence seizures. In absence seizures, a child may exhibit staring spells, brief loss of awareness, and lack of responsiveness, which can last for a few seconds. Choice A is incorrect because the behavior described is not associated with having a crush. Choice B is incorrect as increased intracranial pressure usually presents with other symptoms. Choice C is less likely as a head injury would typically manifest with additional signs beyond just staring and blinking.

3. The nurse is preparing to administer a daily dose of digoxin. What is the priority nursing intervention?

• A. Analyze HR and rhythm
• B. Assess for Homan�s sign
• C. Check BP
• D. Palpate the pedal pulses

Correct answer: A

Rationale: Before giving digoxin, the nurse will assess the HR and rhythm. The dosage will be held and the prescriber notified if the HR is below 60 bpm or if the cardiac rhythm has changes. Digoxin can cause bradycardia and electrical changes in the heart.

4. A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN). Which is the priority nursing diagnosis for this child?

• A. Risk for Injury related to hypertension.
• B. Altered Growth and Development related to chronic disease.
• C. Risk for Infection related to hypertension.
• D. Fluid Volume Excess related to decreased plasma filtration.

Correct answer: A

Rationale: The priority nursing diagnosis for a preschool-age child with acute postinfectious glomerulonephritis (APIGN) is 'Risk for Injury related to hypertension' due to the potential complications such as hypertensive encephalopathy. Hypertension poses an immediate threat to the child's well-being, making it crucial to address the risk for injury associated with elevated blood pressure as the top priority.

5. How would you best evaluate the clinical usefulness of a test?

• A. Decide on using a single test for all clients and families
• B. Consider what needs to be collected and discuss with colleagues
• C. Ask the family for a test suggestion
• D. Read the statistical methods used to validate the scores

Correct answer: B

Rationale: When evaluating the clinical usefulness of a test, the best approach is to consider what specific information needs to be collected based on the clients' needs. Discussing these considerations with colleagues helps in ensuring that the chosen test is appropriate and beneficial for the individuals being assessed. Choice A is incorrect as using a single test for all clients may not account for individual differences. Choice C is incorrect as the family's suggestion alone may not align with clinical needs. Choice D is incorrect as understanding statistical methods alone may not fully capture the clinical utility of a test.

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