Nursing Elites

1. When assessing an adolescent with depression, what is the most important question for the nurse to ask?

• A. What is causing your feelings of depression?
• B. Have you ever thought about suicide?
• C. What actions can we take to improve your mood?
• D. Would you like your friends to come over?

Correct answer: B

Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.

2. What assessment findings should lead the nurse to suspect Down syndrome in a newborn?

• A. Hypertonia and dark skin
• B. Low-set ears and a simian crease
• C. Inner epicanthal folds and a high, domed forehead
• D. Long, thin fingers and excessive hair

Correct answer: B

Rationale: The correct answer is B: 'Low-set ears and a simian crease.' These are key physical characteristics commonly seen in newborns with Down syndrome. Low-set ears, along with a simian crease (a single palmar crease), are indicative of Down syndrome. Choices A, C, and D are incorrect because hypertonia, dark skin, inner epicanthal folds, a high, domed forehead, long, thin fingers, and excessive hair are not specific features associated with Down syndrome in newborns. Therefore, the presence of low-set ears and a simian crease should raise suspicion for Down syndrome and prompt further evaluation.

3. A client with rheumatoid arthritis has elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

• A. Evidence of spread of the disease to the kidney.
• B. Confirmation of the autoimmune disease process.
• C. Representative of a decline in the client's condition.
• D. Indication of the onset of joint degeneration.

Correct answer: B

Rationale: The correct interpretation of elevated serum rheumatoid factor in a client with rheumatoid arthritis is confirmation of the autoimmune disease process. Rheumatoid factor is a marker for autoimmune activity, thus confirming the diagnosis of rheumatoid arthritis. Choice A is incorrect as elevated rheumatoid factor does not specifically indicate spread of the disease to the kidney. Choice C is incorrect as elevated rheumatoid factor does not always represent a decline in the client's condition. Choice D is incorrect as elevated rheumatoid factor is not an indication of the onset of joint degeneration, but rather points towards autoimmune activity.

4. A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity
• B. Fluid volume deficit
• C. Imbalanced nutrition: less than body requirements
• D. Activity intolerance

Correct answer: B

Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.

5. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first?

• A. Evaluate distal capillary refill for delayed perfusion
• B. Check the extremities for bruising and petechiae
• C. Examine the peritibial regions for pitting edema
• D. Palpate the abdomen for tenderness and rigidity

Correct answer: D

Rationale: In a client with a history of cirrhosis and ascites presenting with anorexia and recent hemoptysis, palpating the abdomen for tenderness and rigidity is crucial as it helps in identifying signs of complications related to these conditions. Assessing for abdominal tenderness and rigidity can provide valuable information about the presence of internal bleeding, ascites complications, or liver enlargement. Evaluating distal capillary refill, checking for bruising and petechiae, or examining peritibial regions for pitting edema are important assessments but are not the priority in this case, given the client's history and current symptoms.

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