Nursing Elites

1. Which of the following is TRUE about shock?

• A. A patient with severe shock does not always have an abnormally low blood pressure.
• B. Confusion and deteriorating mentation are indicative of hypotensive shock.
• C. Patients with compensated shock may not be able to maintain a normal blood pressure.
• D. A normal blood pressure does not imply that the patient is stable.

Correct answer: B

Rationale: Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.

2. An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take their child home?

• A. Leave the diapers on to protect the surgical site.
• B. Avoid tub baths until the stent has been removed.
• C. Delay toilet training until the child has fully recovered.
• D. Encourage adequate fluid intake to maintain hydration.

Correct answer: B

Rationale: After surgical repair of hypospadias, the nurse should stress to the parents to avoid giving the child a tub bath until the stent has been removed. This precaution helps prevent infection and ensures proper healing of the surgical site. Leaving diapers on is important to protect the surgical site from contamination. Delaying toilet training is recommended to reduce stress on the child during the recovery period. Encouraging adequate fluid intake is crucial to maintain hydration and support the healing process.

3. The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit data associated with the cause of this disease?

• A. ''Has your child had any nausea or diarrhea?''
• B. ''Have you noticed any rashes on your child?''
• C. ''Did your child recently complain of a sore throat?''
• D. ''Did your child sustain any injuries to the kidney area?''

Correct answer: C

Rationale: The correct answer is 'Did your child recently complain of a sore throat?' Group A beta-hemolytic streptococcal infection is a known cause of glomerulonephritis. In this condition, the child typically becomes ill with streptococcal infection of the upper respiratory tract, and then after 1 to 2 weeks, symptoms of acute poststreptococcal glomerulonephritis can develop. This question aims to gather crucial information related to a potential trigger for glomerulonephritis. Choices A, B, and D are incorrect because they do not pertain to a common cause or associated symptom of glomerulonephritis.

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. Which food should the assistive personnel be instructed to remove from the child's food tray based on the prescribed treatment for nephrotic syndrome?

• A. Pickle
• B. Wheat toast
• C. Baked chicken
• D. Steamed vegetables

Correct answer: A

Rationale: In nephrotic syndrome, a no-added-salt diet is recommended to manage the condition. High-sodium foods like pickles should be avoided as they can exacerbate fluid retention and swelling. Wheat toast, baked chicken, and steamed vegetables are generally suitable for individuals with nephrotic syndrome as they are low in sodium and protein, which are important considerations for this condition. Therefore, the correct choice is to remove the pickles from the child's food tray.

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