Nursing Elites

1. Following a blizzard that resulted in millions of dollars of damage, the community health nurse is planning to seek financial assistance for families affected by the disaster. Which contact is most important for the nurse to make?

• A. the governor's disaster relief program
• B. Federal Emergency Management Agency (FEMA)
• C. local churches that can provide shelter
• D. the community to seek volunteer contributions

Correct answer: B

Rationale: The correct answer is B, the Federal Emergency Management Agency (FEMA). FEMA is the primary agency responsible for providing financial assistance and support during disasters. While the governor's disaster relief program may also offer help, FEMA has more extensive resources and expertise in disaster response. Local churches providing shelter and seeking volunteer contributions from the community are valuable resources but may not offer the comprehensive financial assistance that FEMA can provide in such situations.

2. The nurse identifies a client's needs and formulates the nursing problem of 'Imbalance nutrition: Less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?

• A. Eat 50% of six small meals each day by the end of the week.
• B. Gain 5 pounds by the end of the month.
• C. Have increased caloric intake.
• D. Show improved nutritional status.

Correct answer: A

Rationale: The correct short-term goal for the client in this scenario is option A: 'Eat 50% of six small meals each day by the end of the week.' This goal is specific, measurable, and time-bound, which aligns with the SMART criteria for goal setting in nursing care. It addresses the client's nutritional needs directly, focusing on increasing meal frequency to meet body requirements and counteract weight loss. Option B, 'Gain 5 pounds by the end of the month,' is not as suitable as it lacks specificity and a short-term timeline, making it less achievable within the immediate care plan. Option C, 'Have increased caloric intake,' is vague and does not provide a measurable target for the client to work towards. Option D, 'Show improved nutritional status,' is a broad goal that lacks the specificity needed for effective short-term goal setting in nursing care. Therefore, option A is the most appropriate choice for this client's short-term goal.

3. A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture?

• A. Blurred vision.
• B. Shoulder pain.
• C. Abdominal pain.
• D. Rhinorrhea or otorrhea with halo sign.

Correct answer: D

Rationale: The correct answer is D: Rhinorrhea or otorrhea with halo sign. Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear) are signs of a basilar skull fracture, indicating the need to assess for possible meningeal tears that manifest as a halo sign with cerebrospinal fluid (CSF) leakage from the ears or nose. Choices A, B, and C are incorrect because blurred vision, shoulder pain, and abdominal pain are not typically associated with a basilar skull fracture.

4. A school nurse is organizing a vaccination clinic for middle school students. Which vaccine is most important for the nurse to include?

• A. hepatitis B
• B. tetanus, diphtheria, and pertussis (Tdap)
• C. varicella
• D. measles, mumps, and rubella (MMR)

Correct answer: B

Rationale: The most important vaccine for the school nurse to include in the vaccination clinic for middle school students is the tetanus, diphtheria, and pertussis (Tdap) vaccine. Tdap is recommended for preteens as part of the routine vaccination schedule to protect against these serious diseases. Hepatitis B, varicella, and MMR vaccines are also important but for this specific age group, Tdap takes precedence to ensure protection against tetanus, diphtheria, and pertussis.

5. A client who is receiving total parenteral nutrition (TPN) has an elevated blood glucose level. Which action should the nurse take first?

• A. Stop the TPN infusion.
• B. Administer insulin as prescribed.
• C. Notify the healthcare provider.
• D. Check the TPN infusion rate.

Correct answer: D

Rationale: The correct first action for a client receiving TPN with an elevated blood glucose level is to check the TPN infusion rate. Elevated blood glucose levels in clients receiving TPN can be due to incorrect infusion rates leading to increased glucose delivery. By checking the TPN infusion rate, the nurse can verify if the rate is appropriate and make necessary adjustments. Stopping the TPN infusion abruptly could lead to complications from sudden nutrient deprivation. Administering insulin as prescribed may be necessary but should come after ensuring the correct TPN infusion rate. Notifying the healthcare provider is important but addressing the immediate need to check the infusion rate takes priority to manage hyperglycemia effectively.

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