Nursing Elites

1. A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of which task?

• A. Loss of control
• B. Insecurity
• C. Dependence
• D. Lack of trust

Correct answer: C

Rationale: A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of the task of dependence. Prolonged illness and confinement can lead to the development of dependence as the individual may become reliant on others for their care and needs. Choices A, B, and D are incorrect in this context. Loss of control, insecurity, and lack of trust are important factors to consider but are not directly related to the altered growth and development task of dependence due to illness and confinement.

2. A pre-term baby develops nasal flaring, cyanosis, and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?

• A. Cardiopulmonary resuscitation
• B. Insertion of a chest tube
• C. Oxygen therapy
• D. Assisted ventilation

Correct answer: B

Rationale: The correct answer is B: Insertion of a chest tube. In a case of spontaneous pneumothorax, the primary intervention is to insert a chest tube. This procedure allows the trapped air to escape from the pleural space, relieving pressure and enabling the lung to re-expand. Choices A, C, and D are not the initial interventions for spontaneous pneumothorax. Cardiopulmonary resuscitation is indicated for cardiac arrest, oxygen therapy may provide supportive care but does not address the underlying issue of trapped air in the pleural space, and assisted ventilation may be needed later but is not the first-line treatment for a pneumothorax.

3. The Food Fortification Act of 2000 provides for the mandatory fortification of staple foods, which includes:

• A. Flour with iron
• B. Refined sugar with iron
• C. Cooking oil with vitamin A
• D. Rice with vitamin A

Correct answer: A

Rationale: The correct answer is A: Flour with iron. The Food Fortification Act of 2000 mandates the fortification of flour with iron to address iron deficiency in the population. Refined sugar is not typically fortified with iron, making choice B incorrect. While cooking oil fortification with vitamin A is common in some regions, it is not specified under the Food Fortification Act of 2000, rendering choice C incorrect. Similarly, rice fortification with vitamin A is not included in the mandatory fortification list according to the act, making choice D incorrect.

4. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?

• A. Offer ice chips every 2 hours
• B. Place the child in a semi-Fowler's position
• C. Encourage the child to drink from a cup
• D. Observe swallowing patterns

Correct answer: D

Rationale: Observing swallowing patterns is crucial post-tonsillectomy and adenoidectomy to detect signs of bleeding. Offering ice chips instead of ice cream helps prevent throat irritation. Placing the child in a semi-Fowler's position promotes airway patency and reduces the risk of aspiration. Encouraging the child to drink from a cup instead of a straw minimizes the risk of dislodging the surgical site.

5. During a large community disaster, a man states that the blast threw him out of a second-story window. Which action should the nurse implement first?

• A. Logroll the client to his side and assess for back injuries
• B. Perform a complete neurological assessment
• C. Open the client's airway immediately
• D. Place the nurse's hands around the client's neck to stabilize

Correct answer: D

Rationale: In this situation, the nurse should first stabilize the client's neck to prevent potential spinal cord injuries. Logrolling the client or performing other assessments should only be done after ensuring spinal stabilization. Opening the airway immediately is important in cases of airway obstruction, but stabilizing the neck takes priority in this scenario. Performing a complete neurological assessment may delay immediate stabilization, which is crucial in suspected spinal injuries.

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