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. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only
• B. Maintain intravenous fluid therapy per prescription
• C. Provide Pedialyte feedings via the nasogastric tube
• D. Offer the infant Pedialyte feedings every 2 hours

Correct answer: B

Rationale: Maintaining intravenous fluid therapy is crucial for managing dehydration and electrolyte imbalances caused by the vomiting in hypertrophic pyloric stenosis. Instructing the mother to give sugar water only (Choice A) is not appropriate as it does not address the dehydration and electrolyte imbalances adequately. Providing Pedialyte feedings via the nasogastric tube (Choice C) may not be sufficient to manage the severe fluid and electrolyte losses caused by the condition. Offering Pedialyte feedings every 2 hours (Choice D) may not be as effective as maintaining intravenous fluid therapy, especially in cases where rapid rehydration is necessary.

3. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?

• A. Administer a prescribed PRN antiemetic
• B. Assess the client for the presence of hemorrhoids
• C. Check the client’s hemoglobin level
• D. Review the client’s current list of medications

Correct answer: D

Rationale: The correct action for the nurse to implement in a client experiencing clear, watery diarrhea is to review the client's current list of medications. Certain medications can cause diarrhea as a side effect, so identifying any potential culprits is essential. Administering an antiemetic (Choice A) is not appropriate for diarrhea, as antiemetics are used to control nausea and vomiting, not diarrhea. Assessing for hemorrhoids (Choice B) is not the priority when the client is experiencing watery diarrhea; addressing the root cause is crucial. Checking the client’s hemoglobin level (Choice C) is not the immediate action needed for this situation as it does not directly address the cause of diarrhea.

4. Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

• A. Describes a schedule for antacid use in combination with other prescribed medications
• B. Selects a pattern of small meals interspersed with fluid intake
• C. Commits to engaging in a variety of stress reduction techniques
• D. Expresses a commitment to decrease nicotine intake

Correct answer: B

Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.

5. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Vanilla frozen yogurt
• B. Vegetable juice
• C. Clear beef broth
• D. Canned fruit cocktail

Correct answer: A

Rationale: The correct answer should be provided as choice E: Vanilla frozen yogurt. For a postoperative full liquid diet, the nurse should encourage the client to eat foods that are fully liquid and easy to digest. Vanilla frozen yogurt is a suitable choice as it provides calories and nutrients while being in a liquid form. Creamy peanut butter, vegetable juice, and canned fruit cocktail are not appropriate for a full liquid diet as they are not fully liquid and may not be easy to digest. Creamy peanut butter is solid, vegetable juice is not fully liquid, and canned fruit cocktail contains solid pieces.

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