Nursing Elites

1. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

• A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
• B. Obtain a thorough history and physical assessment from the patient's family member.
• C. Immediately perform a complete history and physical assessment to obtain baseline information.
• D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.

Correct answer: D

Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.

2. What does the medical term 'basophilia' refer to?

• A. An attachment of the epithelial cells of the skin to a basement membrane
• B. An overabundance of a particular white blood cell in the peripheral blood
• C. An underrepresentation of basophils on a blood smear
• D. None of the above

Correct answer: B

Rationale: The correct answer is 'An overabundance of a particular white blood cell in the peripheral blood.' Basophilia specifically indicates an increased number of basophils in the peripheral blood. It can be observed in conditions like leukemia and certain allergic reactions. Choice A is incorrect as it describes something unrelated to basophilia. Choice C is incorrect as it suggests a decrease in basophils, which is opposite to the actual meaning of basophilia. Choice D is also incorrect as basophilia does have a defined medical significance.

3. In a patient with acromegaly, which assessment finding will the nurse expect to find?

• A. Sternal deformity and hyperextensible joints
• B. Growth retardation and a delayed onset of puberty
• C. Overgrowth of bone in the face, head, hands, and feet
• D. Increased height and weight and delayed sexual development

Correct answer: C

Rationale: Acromegaly is a condition characterized by excessive secretion of growth hormone in adulthood after normal body growth completion. This hormonal excess leads to overgrowth of bones in the face, head, hands, and feet; however, there is no significant change in height. Stating sternal deformity and hyperextensible joints is incorrect as they are characteristic findings of Marfan syndrome. Growth retardation and delayed onset of puberty are not typical of acromegaly but are seen in hypopituitary dwarfism. Increased height, weight, and delayed sexual development are features of gigantism, not acromegaly. Therefore, the correct assessment finding in a patient with acromegaly would be overgrowth of bone in the face, head, hands, and feet.

4. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child likely have?

• A. Acromegaly
• B. Marfan syndrome
• C. Hypopituitary dwarfism
• D. Achondroplastic dwarfism

Correct answer: C

Rationale: Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.

5. The client reports nausea and constipation. Which of the following would be the priority nursing action?

• A. Collect a stool sample
• B. Complete an abdominal assessment
• C. Administer an anti-nausea medication
• D. Notify the physician

Correct answer: B

Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.

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