Nursing Elites

1. A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

• A. Children usually resume their toileting behaviors when they leave the hospital
• B. A retraining program will need to be initiated when the child returns home
• C. Diapering will be provided since hospitalization is stressful to preschoolers
• D. A potty chair should be brought from home so he can maintain his toileting skills

Correct answer: A

Rationale: Children often regress in toileting behaviors during hospitalization due to stress and changes in routine. However, they usually resume normal behaviors once they are discharged and back in their familiar environment. Providing reassurance to the parents that the child is likely to return to his previous toileting habits after leaving the hospital can help alleviate their concerns. Choices B, C, and D are incorrect because they do not address the normal pattern of behavior regression and recovery in toileting skills associated with hospitalization.

2. A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?

• A. Rectal temperature of 101°F
• B. Complaints of left shoulder pain
• C. Blood pressure of 88/50 mmHg
• D. Sustained sinus tachycardia

Correct answer: C

Rationale: A blood pressure of 88/50 mmHg indicates possible hypovolemia or shock, which requires immediate attention. Hypotension can be a sign of decreased perfusion to vital organs, potentially leading to organ failure. The other options, such as a rectal temperature of 101°F, complaints of left shoulder pain, or sustained sinus tachycardia, while important, do not present the same level of immediate threat to the client's well-being as a critically low blood pressure.

3. The public health nurse received funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal?

• A. Case management and screening for clients with HIV.
• B. Regional relocation center for earthquake victims.
• C. Vitamin supplements for high-risk pregnant women.
• D. Lead screening for children in low-income housing.

Correct answer: C

Rationale: The correct answer is C: Vitamin supplements for high-risk pregnant women. This option aligns with primary prevention by preventing deficiencies before they occur, which is a key aspect of primary prevention. Providing vitamin supplements to high-risk pregnant women can help prevent birth defects and complications. Choices A, B, and D do not align with primary prevention strategies. Case management and screening for clients with HIV (Choice A) is more of a secondary prevention strategy aimed at early detection and management. A regional relocation center for earthquake victims (Choice B) is focused on addressing the aftermath of a disaster rather than preventing it. Lead screening for children in low-income housing (Choice D) is more about early detection and intervention rather than primary prevention.

4. When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?

• A. Compare the palpated systolic blood pressure with the auscultated pressure
• B. Assess the client for lightheadedness upon standing
• C. Determine if an automated blood pressure reading is consistent with the manual reading
• D. Observe for changes in blood pressure between lying and sitting positions

Correct answer: A

Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.

5. In what order should the nurse assess a lethargic one-hour-old infant brought to the nursery?

• A. Heel stick
• B. Respirations
• C. Heart rate
• D. Temperature

Correct answer: D

Rationale: When assessing a lethargic one-hour-old infant, the nurse should prioritize assessing the most critical parameters first. Temperature and heart rate are vital signs that provide immediate information about the infant's well-being. Therefore, the correct order of assessment should be temperature, heart rate, respirations, and then a heel stick. Temperature is crucial to determine if the infant is hypothermic or hyperthermic, while heart rate gives insight into the circulatory system's function. Respirations follow to evaluate the infant's breathing pattern. Lastly, the heel stick is important for certain screenings but is not as urgent as evaluating temperature and heart rate in a lethargic infant.

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