Nursing Elites

1. 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.

2. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

• A. Ask the client about gastrointestinal pain
• B. Measure the client’s fluid intake and output
• C. Monitor the client’s serum electrolyte levels
• D. Auscultate for bowel sounds in all quadrants

Correct answer: A

Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.

3. The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance?

• A. Wearing gloves when providing care to the client
• B. Encouraging the client to join a support group
• C. Shaking hands with the client during an introduction
• D. Allowing the client to express their feelings openly

Correct answer: B

Rationale: Encouraging the client to join a support group is the best option to address the client's psychosocial need for acceptance. Support groups provide a sense of belonging, understanding, and acceptance from peers who share similar experiences. This helps the client feel accepted despite their condition. Wearing gloves when providing care, shaking hands during an introduction, and allowing the client to express feelings openly are important but do not directly address the client's need for acceptance.

4. During an admission assessment on an HIV positive client diagnosed with Pneumocystis carinii pneumonia (PCP), which symptoms should the nurse carefully observe the client for?

• A. Weight loss exceeding 10 percent of baseline body weight
• B. Altered mental status and tachypnea
• C. Creamy white patches in the oral cavity
• D. Normal ABGs with wet lung sounds in all lung fields

Correct answer: B

Rationale: The correct answer is B: Altered mental status and tachypnea. These symptoms are indicative of PCP and severe HIV progression. Weight loss exceeding 10 percent of baseline body weight (choice A) may be seen in HIV/AIDS but is not specific to PCP. Creamy white patches in the oral cavity (choice C) are characteristic of oral thrush, which is more commonly associated with Candida infections in HIV patients. Normal ABGs with wet lung sounds in all lung fields (choice D) would not be expected with PCP, as it typically presents with hypoxemia and diffuse bilateral infiltrates on chest imaging.

5. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

• A. Observe for an intradermal bleed after the antigen is injected
• B. Select an ID site using the volar surface of the forearm
• C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
• D. Ensure that the needle is inserted into the skin with the bevel up

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

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