Nursing Elites

1. A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?

• A. Apical pulse 58 bpm.
• B. Core body temperature 100.8°F.
• C. Tachypnea with dyspnea.
• D. Multiple bruises over the chest area.

Correct answer: C

Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.

2. What is a causative factor of Hirschsprung disease?

• A. Frequent evacuation of solids, liquid, and gases
• B. Excessive peristaltic movement
• C. The absence of parasympathetic ganglion cells in a portion of the colon
• D. One portion of the bowel telescoping into another

Correct answer: C

Rationale: The correct answer is C: The absence of parasympathetic ganglion cells in a portion of the colon is a causative factor of Hirschsprung disease. This absence leads to the inability of the affected segment of the colon to relax, causing a functional obstruction. Choices A, B, and D are incorrect. Frequent evacuation of solids, liquid, and gases, excessive peristaltic movement, and one portion of the bowel telescoping into another are not causative factors of Hirschsprung disease.

3. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

4. A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?

• A. Observe the perineal area for a chancroid-like lesion.
• B. Obtain a specimen of urethral drainage for culture.
• C. Assess for perineal itching, erythema, and excoriation.
• D. Identify all sexual partners in the last four days.

Correct answer: B

Rationale: In this scenario, the most appropriate action for the nurse to take is to obtain a specimen of urethral drainage for culture. This procedure can help diagnose the cause of burning on urination, which could be indicative of a sexually transmitted infection. Option A, observing for a chancroid-like lesion, may not be the most immediate or relevant action in this case. Option C, assessing for perineal itching, erythema, and excoriation, is important but obtaining a culture specimen would provide more specific diagnostic information. Option D, identifying all sexual partners, is relevant for contact tracing but obtaining a culture specimen is the priority to determine the current infection status.

5. A client with hyperthyroidism is prescribed methimazole. Which adverse effect should the nurse monitor for?

• A. Agranulocytosis
• B. Hypoglycemia
• C. Bradycardia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is Agranulocytosis. Methimazole, used to treat hyperthyroidism, can lead to agranulocytosis, a severe decrease in white blood cells. This condition increases the risk of infections and requires immediate medical attention. Hypoglycemia (choice B) is not a common adverse effect of methimazole. Bradycardia (choice C) is unlikely as methimazole tends to have minimal effects on heart rate. Hypercalcemia (choice D) is not associated with methimazole use.

Similar Questions