Nursing Elites

1. A public health nurse is responsible for the administration of numerous immunizations. Which of the following guidelines regarding anaphylaxis should the nurse adhere to?

• A. The patient should be observed for anaphylaxis for 1 minute after administration.
• B. The patient should be observed for anaphylaxis for 5 minutes after administration.
• C. The patient should be observed for anaphylaxis for 30 minutes after administration.
• D. The patient should be observed for anaphylaxis for 90 minutes after administration.

Correct answer: C

Rationale: The correct answer is C: 'The patient should be observed for anaphylaxis for 30 minutes after administration.' This is because anaphylaxis can occur within minutes of administration of an immunization. By observing the patient for 30 minutes, the nurse can promptly identify and manage any signs of anaphylaxis. Choices A, B, and D are incorrect as they suggest shorter or longer observation periods, which may not be sufficient to detect and respond to anaphylaxis in a timely manner.

2. What physiological reaction occurs in the body with the 'Fight or flight' response?

• A. Increased heart rate
• B. Constricted pupils
• C. Decreased blood pressure
• D. Decreased heart rate

Correct answer: A

Rationale: The 'fight or flight' response is a primal physiological reaction that prepares the body to respond to a perceived threat or danger. This response triggers an increase in heart rate to pump more blood to the muscles and vital organs, preparing the body for action. Choice B, 'Constricted pupils,' is part of the 'fight or flight' response as well, as it helps improve focus and vision. Choice C, 'Decreased blood pressure,' is incorrect because blood pressure typically increases to ensure adequate circulation during the 'fight or flight' response. Choice D, 'Decreased heart rate,' is incorrect as the heart rate increases to supply more oxygen and nutrients to the body during times of stress.

3. A client arrives with symptoms of stroke. What should the nurse assess first?

• A. Level of consciousness
• B. Blood pressure
• C. Pupil reaction
• D. Heart rate

Correct answer: A

Rationale: Assessing the level of consciousness is a critical first step in evaluating a potential stroke. Changes in the level of consciousness can indicate the severity and location of brain damage, helping to guide immediate interventions. Assessing blood pressure, pupil reaction, and heart rate are also important aspects of the assessment in a suspected stroke patient. However, the priority is to quickly determine the client's level of consciousness to assess their neurological status.

4. A client with chronic bronchitis is receiving education from a healthcare provider about the condition. Which statement made by the client indicates a need for further teaching?

• A. I should avoid being around people who smoke.
• B. I should try to avoid any exposure to pollutants and irritants.
• C. I should limit my fluid intake to avoid worsening my cough.
• D. I should use my inhaler regularly, even when I don't have symptoms.

Correct answer: C

Rationale: The correct answer is C because limiting fluid intake is not recommended for chronic bronchitis. Hydration is essential as it helps thin mucus, making it easier to clear from the airways. Choices A, B, and D are all correct statements for managing chronic bronchitis. Avoiding exposure to smoke, pollutants, and irritants can help reduce respiratory symptoms and exacerbations. Using the inhaler regularly, even in the absence of symptoms, is crucial for controlling inflammation and maintaining airway function.

5. A client with multiple sclerosis (MS) is experiencing a relapse. Which of the following factors is most likely contributing to the relapse?

• A. Taking an over-the-counter multivitamin
• B. Experiencing high levels of emotional stress
• C. Getting a flu shot
• D. Engaging in strenuous physical activity

Correct answer: B

Rationale: Emotional stress can trigger a relapse in multiple sclerosis by exacerbating symptoms. While taking an over-the-counter multivitamin and getting a flu shot are generally safe, they are not typically known to trigger MS relapses. Engaging in strenuous physical activity, if done carefully, can actually have benefits for individuals with MS by improving strength and mobility, so it is less likely to be the cause of a relapse.

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