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 female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?

• A. Rented movies and borrowed books to use while passing time at home
• B. Discussing dietary restrictions with the nurse
• C. Arranging follow-up appointments with her oncologist
• D. Reporting to the nurse any new or worsening symptoms

Correct answer: D

Rationale: The correct answer is D because reporting any new or worsening symptoms to the nurse is crucial for the early detection of potential complications. This behavior shows that the client understands the importance of monitoring her health status post-chemotherapy treatment. Choices A, B, and C are incorrect because while renting movies, borrowing books, discussing dietary restrictions, and arranging follow-up appointments are all important aspects of care, the most critical factor immediately after chemotherapy is to monitor and report any new or worsening symptoms to healthcare providers.

3. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbecue that afternoon. What question is most important for the triage nurse to ask this client?

• A. Have you recently traveled outside the United States?
• B. How high was your temperature when you returned home?
• C. Have you taken any medication to treat these symptoms?
• D. Is anyone else sick who was also at the picnic?

Correct answer: D

Rationale: The most important question for the triage nurse to ask the client in this scenario is whether anyone else who attended the picnic is also sick. This is crucial to identify a potential outbreak or common source of infection. Asking about recent travel may be important for infectious diseases but is not as relevant as identifying a common source among individuals who shared the same food. Inquiring about the client's temperature is important but does not provide immediate insight into the cause of symptoms. Asking about medication taken is relevant but not as critical as determining if others are affected, which could indicate a foodborne illness.

4. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out.” The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Splitting
• C. Projection
• D. Rationalization

Correct answer: C

Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.

5. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which finding?

• A. Restlessness
• B. Clenched Fist
• C. Increased pulse rate
• D. Increased respiratory rate

Correct answer: A

Rationale: In infants, restlessness can be a significant indicator of discomfort or pain, necessitating appropriate pain management. While choices B, C, and D can also be associated with pain, restlessness is a more general and reliable indicator in this scenario. A clenched fist might indicate pain or distress, but it is not as specific as restlessness in assessing pain in infants. Increased pulse rate and respiratory rate can be influenced by various factors other than pain, making them less reliable indicators of pain in this context.

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