Nursing Elites

1. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?

• A. Monitor for signs of infection.
• B. Measure abdominal girth and monitor for pain.
• C. Check for bowel movement and changes in stool.
• D. Assess hydration status and monitor urine output.

Correct answer: C

Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.

2. The nurse is caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?

• A. Dizziness
• B. Shortness of breath
• C. Severe chest pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.

3. A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?

• A. Ammonia level
• B. White blood cell count
• C. Albumin level
• D. Hemoglobin level

Correct answer: A

Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.

4. A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Blood glucose 90 mg/dL
• B. Sodium 138 mEq/L
• C. Total calcium 5.0 mg/dL
• D. Potassium 4.2 mEq/L

Correct answer: C

Rationale: A total calcium level of 5.0 mg/dL is critically low and indicates possible hypocalcemia, a common complication after thyroid surgery. This condition can lead to tetany and requires immediate intervention. Blood glucose within normal range, sodium, and potassium levels are not indicative of an immediate postoperative complication like hypocalcemia in this case.

5. When speaking with a group of teens about chemotherapy side effects for cancer, which side effect would the nurse expect this group to be more interested in discussing?

• A. Mouth sores
• B. Fatigue
• C. Diarrhea
• D. Hair loss

Correct answer: D

Rationale: Teens are more likely to be concerned with hair loss when discussing chemotherapy side effects because it is a visible and emotionally impactful side effect for them. While all the listed side effects are important to consider, hair loss can have a significant impact on a teenager's self-image and emotional well-being, making it a key point of interest for this age group. Mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, but they may not carry the same level of emotional weight and visibility as hair loss for teens.

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