Nursing Elites

1. Based on the interpretation of this strip, what action should be implemented first?

• A. Call a code.
• B. Start CPR.
• C. Administer IV fluids.
• D. Apply oxygen.

Correct answer: A

Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.

2. When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?

• A. Limited eye movement.
• B. Decreased peripheral vision.
• C. Blurred distance vision.
• D. Photosensitivity.

Correct answer: B

Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.

3. The cognitive impairment is classified into four levels based on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?

• A. Within the normal low range
• B. Educable
• C. Trainable
• D. Severe

Correct answer: C

Rationale: A child with an IQ of 45 is classified as 'Trainable' in the context of cognitive impairment levels. This category is determined by an IQ range of 35 to 55. Choice A ('Within the normal low range') is incorrect as an IQ of 45 falls within the range associated with the 'Trainable' level, not the 'Normal low range.' Choice B ('Educable') is incorrect because this classification typically corresponds to individuals with slightly higher IQs that allow for academic progress with support. Choice D ('Severe') is incorrect as it does not align with the IQ level of 45, which falls within the 'Trainable' category.

4. When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?

• A. Impaired body image
• B. Skin impairment
• C. Nutritional deficit
• D. Injury

Correct answer: B

Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.

5. What is the hallmark sign of intussusception?

• A. Mucus-like stools
• B. Currant jelly-like stools
• C. Tarry, black stools
• D. Green, soft stools

Correct answer: B

Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.

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