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 female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which interdisciplinary team member should the nurse consult to assist the client?

• A. Contact a hospice nurse for an evaluation
• B. Arrange an appointment with a pain specialist
• C. Ask for a consultation with a psychologist
• D. Form an interdisciplinary team for evaluation

Correct answer: A

Rationale: In this scenario, the most appropriate interdisciplinary team member for the nurse to consult is a hospice nurse. Hospice nurses specialize in managing pain and symptom control, which aligns with the client's needs for managing severe chronic pain. While pain specialists (choice B) focus on pain management, in this case, the client specifically requested hospice care for pain management. Consulting a psychologist (choice C) may be beneficial for addressing psychological aspects, but the client's immediate need is pain management. Forming an interdisciplinary team (choice D) is not as specific as consulting a hospice nurse, who has the specialized skills required to address the client's pain effectively.

3. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?

• A. Administer an anxiolytic
• B. Obtain a 12-lead electrocardiogram
• C. Stop the albuterol administration and restart in 30 minutes
• D. Educate the client about the side effects of albuterol

Correct answer: D

Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.

4. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

5. A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?

• A. Tell the client to have a complete blood count (CBC) drawn
• B. Instruct the client to seek medical attention immediately
• C. Encourage them to take the medication at night with a snack
• D. Explain that these are common side effects of the medication

Correct answer: B

Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.

Similar Questions