Nursing Elites

1. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

• A. Focus on your sons' needs during the first days at home.
• B. Tell each child what he can do to help with the baby.
• C. Suggest that your husband spend more time with the boys.
• D. Ask the children what they would like to do for the newborn.

Correct answer: A

Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.

2. A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?

• A. Prepare the child for an X-ray of the upper airways
• B. Examine the child's throat
• C. Collect a sputum specimen
• D. Notify the healthcare provider of the child's status

Correct answer: D

Rationale: The correct initial action is to notify the healthcare provider of the child's status. The presenting symptoms described, such as irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions, are indicative of epiglottitis, a potentially life-threatening condition. Immediate medical attention is crucial in such cases. While preparing for an X-ray or examining the throat may be necessary, the priority is to ensure prompt evaluation and intervention by the healthcare provider. Collecting a sputum specimen is not relevant in this situation and would cause unnecessary delay. Therefore, the nurse should prioritize communication with the healthcare provider to expedite appropriate management and treatment.

3. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is 615 pg/ml. What would the healthcare provider take as the priority action?

• A. Call for a cardiac evaluation and implement appropriate measures
• B. Check the patient's oxygen saturation
• C. Inform the physician about the elevated BNP level
• D. Encourage the patient to limit physical activity

Correct answer: B

Rationale: An elevated BNP level is indicative of decreased cardiac output, suggesting potential heart failure. In this scenario, the priority action is to check the patient's oxygen saturation. Oxygen saturation assessment is crucial to ensure adequate oxygenation and respiratory function, which is essential in managing cardiac conditions. Calling for a cardiac evaluation and implementing appropriate measures may be necessary but is not the immediate priority without assessing oxygen saturation. Informing the physician about the elevated BNP level can be important for further management but is not the immediate action needed in this situation. Encouraging the patient to limit physical activity might be a consideration later but is not the priority action when dealing with a potential cardiac emergency.

4. A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?

• A. Hyperthermia related to infectious illness
• B. Impaired transfer ability related to weakness
• C. Ineffective airway clearance related to thick secretions
• D. Impaired gas exchange related to respiratory congestion

Correct answer: D

Rationale: The correct answer is 'Impaired gas exchange related to respiratory congestion.' While all the nursing diagnoses are relevant to the patient's condition, the priority should be given to impaired gas exchange due to the patient's low oxygen saturation level of 88%. This indicates a significant risk of hypoxia for all body tissues unless the gas exchange is improved. Addressing impaired gas exchange is crucial to ensure adequate oxygenation and prevent further complications. Hyperthermia, impaired transfer ability, and ineffective airway clearance are important concerns but addressing gas exchange takes precedence in this scenario.

5. The nurse is discussing negativism with the parents of a 30-month-old child. How should the nurse advise the parents to best respond to this behavior?

• A. Reprimand the child and give a 15-minute 'time out'
• B. Maintain a permissive attitude for this behavior
• C. Use patience and a sense of humor to deal with this behavior
• D. Assert authority over the child through limit setting

Correct answer: C

Rationale: Use patience and a sense of humor to deal with this behavior. The nurse should help the parents understand that negativism is a normal part of a toddler's growth towards autonomy. Reacting with patience and humor can help diffuse the situation and maintain a positive relationship with the child. Reprimanding the child and giving a 'time out' (Choice A) may not be effective for addressing negativism and can lead to power struggles. Maintaining a permissive attitude (Choice B) may reinforce negative behavior. Asserting authority through limit setting (Choice D) may be necessary in some situations, but using patience and humor is a more effective initial approach for handling negativism.

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