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 healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?

• A. Measure the client's cardiac output
• B. Assess neurological status q15 min
• C. Collect a blood specimen for serum potassium
• D. Infuse lidocaine (Lidoject-1) at 20 to 50 mg/min

Correct answer: B

Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.

3. When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

• A. Ignore the behavior and administer the IV antibiotic
• B. Tell the client to stop the inappropriate behavior
• C. Leave the room and close the door quietly
• D. Complete an unusual occurrence report

Correct answer: C

Rationale: The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.

4. Following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these findings, what is the client’s greatest risk?

• A. Reduce pulmonary ventilation and oxygenation related to fat embolism.
• B. Neurovascular and circulation compromise related to compartment syndrome.
• C. Wound infection and delayed healing due to fractured bone protrusion.
• D. Venous stasis and thrombophlebitis related to postoperative immobility.

Correct answer: B

Rationale: The correct answer is B. Compartment syndrome is a serious condition that can occur following trauma or surgery, leading to compromised neurovascular status in the affected limb. Symptoms include pain, paresthesia (tingling sensation), and diminished pulses. If left untreated, compartment syndrome can result in tissue damage and potential loss of limb function. Options A, C, and D are incorrect because they do not directly address the neurovascular compromise associated with compartment syndrome.

5. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?

• A. Cramping muscular pain
• B. Worming movements of the tongue
• C. Decreased tendon reflexes
• D. Dry oral mucous membranes

Correct answer: B

Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.

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