Nursing Elites

1. The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?

• A. Perform a complete neurological examination
• B. Measure the child’s head circumference
• C. Check the child’s blood glucose level
• D. Notify the healthcare provider immediately

Correct answer: D

Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment. Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected. Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation. Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.

2. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

• A. Transport a client who is receiving IV fluid to the radiology department
• B. Administer PRN oral analgesics to a client with a history of chronic pain
• C. Supervise a newly hired graduate nurse during an admission assessment
• D. Complete ongoing focused assessments of a client with wrist restraints

Correct answer: C

Rationale: The correct answer is C because supervising a newly hired graduate nurse during an admission assessment is a task that falls within the registered nurse's scope of practice. Registered nurses are responsible for overseeing and delegating tasks, especially to new staff, to ensure proper assessment and care delivery. Choices A, B, and D involve tasks that can be appropriately assigned to practical nurses or unlicensed assistive personnel as they are within their scope of practice. Transporting a client, administering oral analgesics, and completing focused assessments do not require the advanced knowledge and skills of a registered nurse.

3. A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?

• A. Noncompliance with medication related to thought broadcasting
• B. Situational self-esteem disturbance secondary to schizophrenia
• C. Disturbed sensory perception related to auditory hallucinations
• D. Impaired environmental interpretation related to paranoid delusions

Correct answer: D

Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.

4. The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?

• A. Inability to touch their toes
• B. Asymmetry of the shoulders when standing upright
• C. Audible crepitus when bending
• D. An exaggerated upper thoracic convex curvature

Correct answer: B

Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.

5. Identify the placement of the stapes footplate into the bony labyrinth.

• A. Fenestra vestibuli
• B. Fenestra cochleae
• C. Tympanic membrane
• D. Round window

Correct answer: A

Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.

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