Nursing Elites

1. While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?

• A. Positive Homan's sign
• B. Fever and chills
• C. Dyspnea and cough
• D. Sensory impairment

Correct answer: C

Rationale: The correct answer is C: 'Dyspnea and cough.' Pulmonary embolism often presents with a sudden onset of dyspnea (difficulty breathing) and cough, which are due to the obstruction of blood flow in the pulmonary arteries. Choices A, B, and D are incorrect. Positive Homan's sign is associated with deep vein thrombosis, fever and chills are nonspecific symptoms commonly seen in infective endocarditis, and sensory impairment is not typically indicative of pulmonary embolism.

2. The nurse is planning care for a client with increased intracranial pressure. The best position for this client is

• A. Trendelenburg
• B. Prone
• C. Semi-Fowler's
• D. Side-lying with head flat

Correct answer: C

Rationale: The correct answer is C, Semi-Fowler's. This position helps to reduce intracranial pressure by promoting venous drainage from the head while maintaining adequate oxygenation. Option A, Trendelenburg position, is incorrect as it involves placing the patient with the head lower than the body, which can increase intracranial pressure. Option B, Prone position, is also incorrect as it involves lying on the stomach, which can further elevate intracranial pressure. Option D, Side-lying with head flat, does not provide the same benefits as the Semi-Fowler's position in terms of promoting venous drainage and maintaining oxygenation in a client with increased intracranial pressure.

3. The client with acute hypocalcemia is admitted to the unit. Nursing action should include:

• A. Implement seizure precautions
• B. Assess for hypoglycemia
• C. Monitor for visual changes
• D. Observe for muscle weakness

Correct answer: A

Rationale: The correct action for a client with acute hypocalcemia is to implement seizure precautions. Hypocalcemia can lead to tetany and seizures due to neuromuscular irritability. Assessing for hypoglycemia (choice B) is not directly related to hypocalcemia. Monitoring for visual changes (choice C) is more indicative of conditions like hyperglycemia or retinal disorders. Observing for muscle weakness (choice D) is a common symptom of hypocalcemia but does not address the immediate risk of seizures, which is why implementing seizure precautions is the priority nursing action.

4. The nurse is planning a nutrition class for a group of high school students emphasizing the goals for nutrition from Healthy People 2020. Which meal selection provides the best choices in meeting these goals?

• A. pasta with cheese sauce, garlic butter bread, and vegetable juice drink
• B. a 6-oz pork chop, creamed peas, cheese sauce on potatoes, coffee
• C. vegetable lasagna, lettuce salad, a whole wheat roll, 8 oz of 2% milk
• D. bacon, lettuce, tomato sandwich, whole grain chips, 8 oz. of whole milk

Correct answer: C

Rationale: The correct answer is C because vegetable lasagna, lettuce salad, and a whole wheat roll with 2% milk align with the nutrition goals of Healthy People 2020. These choices provide a balanced meal with vegetables, whole grains, and dairy, promoting a healthier dietary pattern. Choices A, B, and D do not offer as comprehensive a selection of food groups or as healthy options as choice C, making them less aligned with the nutrition goals of Healthy People 2020.

5. A nurse is practicing community health nursing when:

• A. leading a support group for obese adolescents
• B. visiting an old woman in her condominium to change her postsurgical dressing
• C. being in a clinic instructing a couple about newborn care
• D. performing any of these activities

Correct answer: D

Rationale: Correct! Community health nursing involves a broad scope of activities that focus on promoting and preserving the health of populations rather than individuals. This includes leading support groups, providing home care, and educating communities. The other options represent different aspects of nursing care such as home health nursing, wound care, and maternal-child health - which are not exclusive to community health nursing.

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