Nursing Elites

1. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

• A. Increased tactile fremitus
• B. Dry, nonproductive cough
• C. Hyperresonance to percussion
• D. A grating sound on auscultation

Correct answer: A

Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias, such as pneumococcal pneumonia. Dullness to percussion would be expected due to consolidation. Pneumococcal pneumonia typically presents with a loose, productive cough rather than a dry, nonproductive cough. Hyperresonance to percussion is not a typical finding in pneumonia and may suggest conditions like emphysema. Adventitious breath sounds such as crackles and wheezes are typical in pneumonia, but a grating sound on auscultation is more representative of a pleural friction rub rather than pneumonia.

2. A patient is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?

• A. Immobilize the cervical area to prevent further injury
• B. Monitor the patient's level of consciousness to prevent neurologic deterioration
• C. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
• D. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing

Correct answer: D

Rationale: The correct answer is to facilitate tissue perfusion to the spinal cord while maintaining airway and breathing. In the acute phase of a spinal cord injury, ensuring proper tissue perfusion to the spinal cord is crucial to prevent further damage. Maintaining airway, breathing, and circulation is essential in guiding the overall care for a patient with a spinal cord injury. Choices A, B, and C, while important in certain aspects of care, are not the overarching principles that guide the immediate management of a suspected spinal cord injury.

3. The nurse is writing out discharge instructions for the parents of a child diagnosed with celiac disease. The nurse should focus primarily on which aspect of care?

• A. Restricting activity
• B. Following a gluten-free diet
• C. Following a lactose-free diet
• D. Giving medication to manage the condition

Correct answer: B

Rationale: The primary nursing consideration in the care of a child with celiac disease is to instruct the child and parents about proper dietary management. The cornerstone of managing celiac disease is maintaining a strict gluten-free diet to prevent symptoms and long-term complications. While medications may be part of the treatment plan, dietary adjustments, particularly following a gluten-free diet, are crucial for managing the condition effectively. Restricting activity is not the primary focus of care for celiac disease. A lactose-free diet is not typically necessary unless the child also has lactose intolerance, which is distinct from celiac disease.

4. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?

• A. Hepatitis testing
• B. Tuberculosis screening
• C. Contraceptive teaching
• D. Colonoscopy information

Correct answer: B

Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.

5. Which of the following is NOT a warning sign that compensatory mechanisms in a patient in shock are failing?

• A. Increasing heart rate above normal for the patient's age.
• B. Absent peripheral pulses
• C. Decreasing level of consciousness
• D. Increasing blood pressure

Correct answer: D

Rationale: In a patient in shock, increasing blood pressure is not a sign that compensatory mechanisms are failing. As shock progresses and compensatory mechanisms fail, systolic blood pressure will decrease, leading to hypotension, which is a late and ominous sign in these patients. Therefore, choices A, B, and C are warning signs of failing compensatory mechanisms in shock: an increasing heart rate above normal, absent peripheral pulses, and decreasing level of consciousness, respectively. An increasing blood pressure is not indicative of compensatory failure in shock; instead, it may be a sign of compensatory mechanisms still trying to maintain perfusion pressure.

Similar Questions