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. As a community Health Nurse, you are a change agent. Which of the following roles must you play to succeed as a change agent?

• A. information provider
• B. information seeker
• C. motivator
• D. leader

Correct answer: B

Rationale: To succeed as a change agent, being an information seeker is crucial. While being an information provider, motivator, and leader are important roles, actively seeking information is fundamental to understanding the community's needs, concerns, and challenges before implementing effective changes. This active information seeking helps in making informed decisions and developing strategies that address the specific issues faced by the community. Therefore, the correct choice is B. Choices A, C, and D are also important roles but may not be as fundamental as actively seeking information.

3. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is

• A. High risk for infection related to vomiting
• B. Altered family processes related to chronic illness
• C. Fluid volume deficit related to vomiting
• D. Risk for aspiration related to loss of consciousness

Correct answer: D

Rationale: Risk for aspiration is a priority concern following a seizure, especially when the child vomits, as there is a danger of aspirating the vomit into the lungs, leading to respiratory complications. The other options are not the priority in this situation. While infection risk and fluid volume deficit are important, ensuring the child's airway is clear and there is no risk of aspiration takes precedence. Altered family processes may be a concern but addressing the immediate physiological risk is the priority.

4. Which of the following best describes the goal of primary health care?

• A. Treating chronic diseases
• B. Providing specialized medical services
• C. Promoting health and preventing illness
• D. Conducting medical research

Correct answer: C

Rationale: The correct answer is C: 'Promoting health and preventing illness.' Primary health care aims to provide essential health services, promote health, prevent diseases, and manage common health problems. Choices A, B, and D are incorrect because primary health care focuses on a holistic approach to health that includes health promotion, disease prevention, treatment of common illnesses, and community participation, rather than specialized services, chronic disease treatment, or medical research.

5. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?

• A. Offer ice chips every 2 hours
• B. Place the child in a semi-Fowler's position
• C. Encourage the child to drink from a cup
• D. Observe swallowing patterns

Correct answer: D

Rationale: Observing swallowing patterns is crucial post-tonsillectomy and adenoidectomy to detect signs of bleeding. Offering ice chips instead of ice cream helps prevent throat irritation. Placing the child in a semi-Fowler's position promotes airway patency and reduces the risk of aspiration. Encouraging the child to drink from a cup instead of a straw minimizes the risk of dislodging the surgical site.

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