Nursing Elites

1. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?

• A. Arrange to change client care assignments.
• B. Explain that this behavior is expected.
• C. Discuss the appropriate use of 'time-out'.
• D. Explain that the child needs extra attention.

Correct answer: B

Rationale: The correct answer is to explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parents, crying, and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool. Changing client care assignments (Choice A) is not necessary as the child's behavior is developmentally appropriate. Discussing the appropriate use of 'time-out' (Choice C) is not relevant in this situation as the child is displaying normal attachment behavior, not misbehavior. Explaining that the child needs extra attention (Choice D) may not be necessary as the child is likely seeking comfort from the familiar presence of the mother, which is a typical response in a stressful situation like being in a hospital environment.

2. What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?

• A. Ask where the client obtained the alcohol.
• B. Locate the alcoholic substance.
• C. Convey empathy and support to the client.
• D. Document the client's drinking behavior.

Correct answer: B

Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.

3. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

• A. Instruct in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique to change the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

4. How is the secondary use of data from the 2000 census classification system utilized to address disparities in mental health care along racial-ethnic lines?

• A. To provide culturally relevant care to the required ethnic group
• B. To identify all racial and ethnic groups in the United States
• C. To identify why there are disparities in the United States
• D. To determine when and how the health care needs of the ethnic populations are being met

Correct answer: D

Rationale: The census classification system categorizes individuals based on racial and ethnic descriptions. Utilizing this data helps in identifying health disparities and assessing how the health care needs of ethnic populations are being addressed. Option A is incorrect because the primary focus is on analyzing healthcare needs met, not providing care. Option B is incorrect as the census does not encompass every single racial and ethnic group in the United States. Option C is incorrect as the census is not designed to investigate the reasons behind disparities, but rather to quantify and analyze them.

5. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

• A. At home, I take my pills at 8:00 am.
• B. It costs a lot of money to buy all of these pills.
• C. I get so tired of taking pills every day.
• D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.

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