Nursing Elites

1. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

• A. Lymphedema and nerve palsy
• B. Hearing loss and ataxia
• C. Headaches and vomiting
• D. Abdominal mass and weakness

Correct answer: D

Rationale: Neuroblastoma, a common solid tumor in children, often presents with symptoms related to the mass effect it causes. Abdominal mass and weakness are classic signs of neuroblastoma due to the tumor originating in the adrenal glands near the kidneys and potentially compressing nearby structures. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more common in conditions affecting the central nervous system rather than neuroblastoma. Headaches and vomiting (Choice C) are nonspecific symptoms and are less commonly linked to neuroblastoma compared to the characteristic abdominal findings.

2. A healthcare professional is assessing a client’s extraocular eye movements. Which of the following should the professional do?

• A. Instruct the client to follow a finger through the six cardinal positions of gaze.
• B. Hold a finger 46 cm (18 in) away from the client’s eyes.
• C. Ask the client to cover their right eye during assessment of the left eye.
• D. Position the client 6.1 m (20 feet) away from the Snellen chart.

Correct answer: A

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.

3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102°F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?

• A. Temperature
• B. Menses overdue
• C. Soft tender abdomen
• D. Heart rate

Correct answer: A

Rationale: The correct answer is A: Temperature. A high temperature of 39.2°C (102°F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.

4. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the nurse to take?

• A. Monitor the client's blood glucose level.
• B. Encourage the client to increase fluid intake.
• C. Administer insulin as prescribed.
• D. Assess the client's urine output.

Correct answer: A

Rationale: The most critical action for the nurse to take when a client with diabetes mellitus presents with symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps in assessing the client's current glycemic status and guides further interventions. Encouraging increased fluid intake (Choice B) may be beneficial in managing dehydration caused by polyuria, but it does not address the underlying cause of hyperglycemia. Administering insulin as prescribed (Choice C) may be necessary based on the blood glucose monitoring results, but monitoring should precede any medication administration. Assessing the client's urine output (Choice D) is important but does not directly address the primary concern of evaluating and managing hyperglycemia in a client with diabetes.

5. A healthcare provider is preparing to perform mouth care for an unresponsive client. Which of the following actions should the healthcare provider plan to take?

• A. Raise the level of the bed
• B. Administer mouth care with the client in a supine position
• C. Use a tongue depressor to open the mouth
• D. Place the client in a prone position

Correct answer: A

Rationale: Raising the bed level is the correct action to facilitate easier access for mouth care in an unresponsive client. This position enhances the safety and comfort of both the client and the healthcare provider. Administering mouth care with the client in a supine position (lying flat on their back) can increase the risk of aspiration. Using a tongue depressor to open the mouth is not recommended as it can cause discomfort and potential injury. Placing the client in a prone position (lying face down) is contraindicated for mouth care and can compromise the client's airway.

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