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. The client enters the room of a client with Parkinson’s disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?

• A. Demonstrate how to help the client move more efficiently
• B. Offer a PRN analgesic to reduce painful movement
• C. Affirm that the client should arise slowly from the chair
• D. Tell the UAP to assist the client in moving more quickly

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.

3. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client’s right leg?

• A. Dorsiflexes the right foot and left foot on command
• B. A 3 by 5 cm ecchymosis area on the right calf
• C. Right calf is 3 cm larger in circumference than the left calf
• D. Bilateral lower extremities have 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant difference in calf circumference between the legs is a classic sign of DVT. This is due to the obstruction of blood flow in the deep veins of the leg, leading to swelling in the affected limb. Choices A, B, and D are not typical findings of DVT. Choice A describes a neurological response, choice B indicates a bruise on the right calf, and choice D describes pitting edema in both lower extremities, which are not specific signs of DVT.

4. 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.

5. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?

• A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
• B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
• C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
• D. Encourage the client to avoid becoming involved in the neighbor’s problems for one’s protection.

Correct answer: C

Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.

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