Nursing Elites

1. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

• A. Pleuritic pain on inspiration
• B. Dry mucus membranes in the mouth
• C. A decrease in respiratory rate from 34 to 24
• D. Decrease in chest wall expansion

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

2. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

• A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
• B. Place the client into the bed and administer the ordered PRN analgesic
• C. Check the client for bladder distention and the client's urinary catheter for kinks
• D. Turn the television off and then assist client to use relaxation techniques

Correct answer: C

Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.

3. A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago. To confirm the presence or absence of an infection, it is most important for all family members to have a

• A. Chest x-ray
• B. Blood culture
• C. Sputum culture
• D. PPD intradermal test

Correct answer: D

Rationale: The PPD (purified protein derivative) intradermal test is the standard screening method for detecting tuberculosis infection. It helps identify individuals who have been infected with Mycobacterium tuberculosis. A chest x-ray (Choice A) is used to assess the extent of active disease, not for screening purposes. Blood culture (Choice B) is not typically used for tuberculosis screening. Sputum culture (Choice C) is used to confirm active tuberculosis in symptomatic individuals, not for initial screening purposes.

4. The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?

• A. B, D, and K
• B. A, D, and K
• C. A, C, and D
• D. A, B, and C

Correct answer: B

Rationale: Children with cystic fibrosis often have difficulty absorbing fat-soluble vitamins (A, D, and K) due to pancreatic insufficiency, making supplementation necessary. Choice A (B, D, and K) is incorrect because vitamin A deficiency is not commonly associated with cystic fibrosis. Choice C (A, C, and D) is incorrect as vitamin C deficiency is not typically related to cystic fibrosis. Choice D (A, B, and C) is incorrect as vitamin B deficiencies are not commonly seen in cystic fibrosis but rather fat-soluble vitamin deficiencies.

5. As a community health nurse covering a cluster of Barangays, your population coverage includes the following:

• A. Families in their homes, School population, Workers in factories
• B. Families in their homes, School population, Patients in hospital
• C. All except workers in factories
• D. All except patients in hospital

Correct answer: A

Rationale: The correct answer is A: 'Families in their homes, School population, Workers in factories.' As a community health nurse, you are responsible for providing healthcare services and promoting health within the community. This includes visiting families in their homes to assess their health needs, working with the school population to educate them on preventive health measures, and ensuring the health and safety of workers in factories. Choices B, C, and D are incorrect because they do not encompass the full scope of a community health nurse's responsibilities. Choice B does not include workers in factories, Choice C excludes an important population group, and Choice D excludes an essential setting where healthcare services are provided.

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