Nursing Elites

1. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.

• A. Providing a low-fat, well-balanced diet.
• B. Teaching the child effective hand-washing techniques.
• C. Notifying the primary health care provider (PHCP) if jaundice is present.
• D. Instructing the parents to avoid administering medications unless prescribed.

Correct answer: D

Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.

2. Using the illustrated technique, the healthcare provider is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?

• A. Hyperresonance
• B. Tripod positioning
• C. Accessory muscle use
• D. Reduced chest expansion

Correct answer: D

Rationale: The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest expansion would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion, not palpation. Accessory muscle use and tripod positioning would be assessed by inspection, not palpation.

3. Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent's remark: "We just don't know how he caught the disease!"? The nurse's response is based on an understanding that:

• A. AGN is a streptococcal infection that involves the kidney tubules.
• B. The disease is easily transmissible in schools and camps.
• C. The illness is usually associated with chronic respiratory infections.
• D. It is not "caught"? but is a response to a previous B-hemolytic strep infection.

Correct answer: D

Rationale: The correct answer is that acute glomerulonephritis (AGN) is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease triggered by an antecedent streptococcal infection occurring 4 to 6 weeks prior. It is considered a noninfectious renal disease. Choice A is incorrect because AGN is not a streptococcal infection that involves the kidney tubules but rather a noninfectious renal disease. Choice B is incorrect as AGN is not easily transmissible in schools and camps but is a result of a previous streptococcal infection. Choice C is incorrect as AGN is not usually associated with chronic respiratory infections, but with a previous streptococcal infection.

4. Mr. V is receiving treatment for a spinal cord injury after falling off of his deck at home. He has undergone spinal surgery and has been placed in a halo traction device. Which of the following nursing interventions is most appropriate for a client with a spinal cord injury?

• A. Turn the client and use incentive spirometry each shift
• B. Administer stool softeners as ordered
• C. Turn the head slowly to avoid further damage to the spine
• D. Change NPO status

Correct answer: B

Rationale: In a client with a spinal cord injury, administering stool softeners as ordered is a crucial nursing intervention. Patients with spinal cord injuries are at higher risk of constipation due to decreased mobility. Stool softeners help prevent constipation and potential fecal impaction. Turning the client and using incentive spirometry each shift can be beneficial for respiratory function but is not the most vital intervention in this scenario. Turning the head slowly to avoid further damage to the spine is important but is not directly related to preventing constipation. Changing NPO status is not relevant to preventing constipation or managing a spinal cord injury.

5. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?

• A. Induce vomiting
• B. Hold the next dose of Lithium
• C. Administer an antiemetic
• D. Give the next dose of Lithium

Correct answer: B

Rationale: The correct answer is to hold the next dose of Lithium. The blood lithium value of 1.7 mcg/L exceeds the therapeutic range of 0.5-1.5 mcg/L, indicating potential toxicity. Holding the next dose is crucial to prevent further accumulation of lithium in the bloodstream. Inducing vomiting is not appropriate in this situation as the priority is to prevent further absorption of lithium. Administering an antiemetic is not the priority in lithium toxicity. Giving the next dose of lithium would exacerbate the toxicity and should be avoided.

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