Nursing Elites

1. In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?

• A. ability to breathe
• B. pallor or cyanosis of the skin
• C. number of accompanying family members
• D. motor function

Correct answer: C

Rationale: During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.

2. During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?

• A. Ask the television crew to interview the individuals attending the program individually.
• B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
• C. Explain to the television crew that videotaping is not allowed.
• D. Allow the television crew to videotape the program.

Correct answer: C

Rationale: Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.

3. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?

• A. The history and presentation might indicate chickenpox, a highly contagious disease.
• B. The lesions might indicate a noncontagious infection that does not require isolation.
• C. The history and presentation might indicate an infectious illness called impetigo.
• D. The lesions are not contagious unless others have open wounds or lesions themselves.

Correct answer: C

Rationale: The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy. Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever. Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection. Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.

4. Which of these would be the most appropriate way to document a client's refusal of medication?

• A. "Heparin refused during shift. Risks reviewed."?
• B. "The client refused the heparin injection when I tried to administer it. She yelled at me, saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift."?
• C. "Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client, and the client verbalized understanding."?
• D. "Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct, and the ct verbalized understanding."?

Correct answer: C

Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.

5. Which of the following statements is true about syphilis?

• A. The cause and mode of transmission are well understood.
• B. There is no known cure for the disease.
• C. When the primary lesion heals, the disease is cured.
• D. Syphilis can be cured with a course of antibiotic therapy.

Correct answer: D

Rationale: The correct statement about syphilis is that it can be cured with a course of antibiotic therapy. Syphilis is a treponemal disease that can be effectively treated with antibiotics, particularly long-acting penicillin G. The primary lesion of syphilis, known as a chancre, typically appears about three weeks after exposure and can involute even without specific treatment. If left untreated, secondary manifestations may occur, followed by latent periods. Specific treatment with antibiotics is crucial to prevent progression and transmission of the disease. Therefore, option D is correct. Option A is incorrect because the cause and mode of transmission of syphilis are well understood. Option B is incorrect as there is a known cure for syphilis. Option C is incorrect because the healing of the primary lesion does not indicate a cure for the disease.

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