Nursing Elites

1. When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?

• A. Wash hands frequently
• B. Avoid drinking lake water
• C. Wear long sleeves and pants
• D. Do not share personal products

Correct answer: C

Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.

2. The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?

• A. Assess extremity strength and resistance
• B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
• C. Measure and record the cardiac QRS complex
• D. Check current finger stick glucose

Correct answer: D

Rationale: The client’s symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.

3. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. The client is experiencing difficulty breathing and is very anxious. The nurse notes that the client’s oxygen saturation is 88% on room air. Which action should the nurse implement first?

• A. Place the client in a high Fowler’s position
• B. Administer supplemental oxygen
• C. Perform a thorough respiratory assessment
• D. Start an IV infusion of normal saline

Correct answer: B

Rationale: Administering supplemental oxygen is the first priority to address low oxygen saturation and ease breathing. In a client with COPD experiencing difficulty breathing and anxiety with oxygen saturation at 88%, providing supplemental oxygen takes precedence over other actions. Placing the client in a high Fowler’s position may help with breathing but does not address the immediate need for increased oxygenation. Performing a thorough respiratory assessment is important but should come after stabilizing the client's oxygen levels. Starting an IV infusion of normal saline is not the priority in this situation and does not directly address the client's respiratory distress.

4. In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?

• A. Does she know the person who raped her?
• B. Has she taken a bath since the rape occurred?
• C. Is the place where she lives a safe place?
• D. Did she report the rape to the police department?

Correct answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

5. Which action should the school nurse take first when conducting a screening for scoliosis?

• A. Compare dorsal trunk measurements
• B. Have the individual extend arms over the head for visualization
• C. Inspect for symmetrical shoulder height
• D. Observe weight-bearing on each leg

Correct answer: C

Rationale: Inspecting for symmetrical shoulder height is a crucial initial step in screening for scoliosis. Asymmetry in shoulder height can indicate the presence of spinal curvature, which is a key indicator of scoliosis. This assessment is prioritized as it provides a visual clue to potential spinal abnormalities. Choices A, B, and D are not the first steps in scoliosis screening. Choice A involves a more detailed measurement that is not the primary visual indicator for scoliosis; choice B is not a primary indicator of scoliosis but can be used for further examination, and choice D is not directly related to identifying spinal curvature.

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