Nursing Elites

1. 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.

2. A client who had a cerebrovascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client’s current health status?

• A. Risk for impaired tissue integrity related to impaired physical mobility
• B. Impaired skin integrity related to altered circulation and pressure
• C. Ineffective tissue perfusion related to inability to move self in bed
• D. Impaired physical mobility related to the left-side paralysis

Correct answer: B

Rationale: The correct answer is B: 'Impaired skin integrity related to altered circulation and pressure.' This nursing diagnosis is the most appropriate as it directly addresses the Stage II pressure ulcer on the left hip, which is caused by altered circulation and pressure due to the client's left-side paralysis. Choice A is incorrect because it focuses on the risk for impaired tissue integrity rather than the current issue of impaired skin integrity. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this scenario. Choice D is incorrect as it only addresses the left-side paralysis and not the pressure ulcer or altered circulation.

3. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first?

• A. A 38-week primigravida who reports contractions occurring every 10 minutes
• B. A 39-week primigravida with a biophysical profile score of 5 out of 8
• C. A 41-week multigravida who is scheduled for induction of labor today
• D. A 36-week multigravida with a prescription for serial blood pressure

Correct answer: B

Rationale: The correct answer is B. A biophysical profile score of 5 out of 8 indicates potential fetal distress, necessitating immediate assessment to ensure the well-being of the fetus. The other options, while important, do not suggest an immediate threat to the fetus' health. The 38-week primigravida with contractions every 10 minutes may be in early labor, the 41-week multigravida scheduled for induction can be assessed after addressing the immediate concern, and the 36-week multigravida with serial blood pressure can be assessed after ensuring the client with potential fetal distress is stabilized.

4. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

• A. The client has asymmetrical chest expansion
• B. Percussion reveals dullness over the lung area
• C. Bilateral breath sounds can be auscultated
• D. The client has been turned q2h

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

5. A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

• A. Encourage the use of corrective lenses during the day
• B. Practice visual exercises that focus on a still object
• C. Alternate an eye patch from eye every 2 hours
• D. Teach techniques for scanning the environment

Correct answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

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