Nursing Elites

1. In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?

• A. measles, polio, pertussis, hepatitis B
• B. diphtheria, pertussis, polio, tetanus
• C. rubella, polio, pertussis, hepatitis A
• D. measles, mumps, rubella, polio

Correct answer: B

Rationale: By 12 months of age, children should have received the DTaP (diphtheria, pertussis, and tetanus) vaccine along with the polio vaccine. The MMR (measles, mumps, and rubella) vaccine is not typically given until the child is 12-15 months old. Therefore, option B is correct as it includes vaccines that are usually administered by 12 months of age. Options A, C, and D are incorrect as they include vaccines that are typically given after 12 months of age.

2. A nurse is reviewing the medical record of an older client with presbycusis. Which finding would the nurse expect to note in the client's record?

• A. Difficulty hearing whispered words in the voice test
• B. Improved hearing ability during conversational speech
• C. Unilateral conductive hearing loss
• D. Difficulty hearing low-pitched tones

Correct answer: A

Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and consonants during conversational speech. Choice A is correct because it reflects the expected finding in presbycusis. Choices B, C, and D are incorrect because presbycusis does not result in improved hearing ability during conversational speech, unilateral conductive hearing loss, or difficulty hearing low-pitched tones.

3. A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?

• A. Allow the toddler to play with other children in the nursing unit playroom.
• B. Spend as much time as possible with the toddler.
• C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room.
• D. Keep hospital routines as similar as possible to those at home.

Correct answer: D

Rationale: The best action for the nurse to take to help a hospitalized toddler maintain a sense of control and security and ease feelings of helplessness and fear is to keep hospital routines as similar as possible to those at home. By incorporating the toddler's usual rituals and routines from home into nursing care activities, the nurse can reduce the stress of hospitalization. This approach gives the toddler a sense of familiarity, control, and security, which can alleviate feelings of helplessness and fear. Allowing the toddler to play with other children in the nursing unit playroom and selecting toys are beneficial activities, but maintaining hospital routines similar to those at home is the most effective way to support the toddler's emotional well-being during hospitalization.

4. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

5. A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?

• A. Contacting the registered nurse
• B. Documenting the findings
• C. Wrapping an extra blanket around the infant
• D. Placing the infant in an oxygen tent

Correct answer: B

Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.

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