Nursing Elites

1. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

• A. Focus on your sons' needs during the first days at home.
• B. Tell each child what he can do to help with the baby.
• C. Suggest that your husband spend more time with the boys.
• D. Ask the children what they would like to do for the newborn.

Correct answer: A

Rationale: The correct answer is A. Focusing on the older children's needs during the initial days at home is crucial as it helps them feel secure and valued during the transition. This approach allows the children to adjust to the new family dynamics and feel included in the care of their newborn sister. Choice B is incorrect as it focuses on tasks rather than addressing the children's emotional needs. Choice C is not the initial step and does not involve directly addressing the children's needs. Choice D puts the decision-making burden on the children rather than providing guidance and support.

2. What is the most common cause of vaginal bleeding immediately after birth?

• A. Uterine atony
• B. Genital lacerations
• C. Abnormal clotting mechanism
• D. Endometritis

Correct answer: A

Rationale: Vaginal bleeding immediately after birth is most often due to uterine atony, which is the failure of the uterus to contract following delivery. This results in inadequate compression of blood vessels at the placental site, leading to hemorrhage. Genital lacerations and abnormal clotting mechanisms can also cause bleeding but are less common immediately after birth compared to uterine atony. Endometritis, inflammation of the lining of the uterus, usually presents with symptoms like fever and pelvic pain rather than immediate postpartum bleeding.

3. What is an important basis in preparing the family health care plan?

• A. Needs and problems gathered and recognized by the nurse herself
• B. Data gathered from the health center
• C. Needs and problems as seen and accepted by the family
• D. Needs as expected by the midwife assigned in the area where the family resides

Correct answer: C

Rationale: In preparing a family health care plan, it is crucial to consider the needs and problems as perceived and accepted by the family members themselves. This ensures that the plan aligns with the family's beliefs, values, and preferences, leading to better acceptance and adherence. Choices A, B, and D are incorrect because the active involvement and acceptance of the family in recognizing their needs and problems are essential for effective health care planning.

4. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

• A. Expiratory wheezes
• B. Blurred vision
• C. Ascites
• D. Dilated pupils

Correct answer: C

Rationale: Ascites is a common finding in clients with portal hypertension. Portal hypertension results in increased pressure in the portal vein, leading to the development of ascites, which is the accumulation of fluid in the abdominal cavity. Expiratory wheezes (Choice A) are associated with respiratory conditions. Blurred vision (Choice B) is more commonly linked to eye disorders or neurological issues. Dilated pupils (Choice D) can be related to neurological conditions or drug effects, but not specifically to portal hypertension.

5. A client with a history of hypertension is receiving enalapril (Vasotec). The nurse should monitor the client for which of the following side effects?

• A. Hyperkalemia
• B. Hypoglycemia
• C. Hypercalcemia
• D. Hypokalemia

Correct answer: A

Rationale: The correct answer is A: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia as a side effect. ACE inhibitors can cause potassium retention by inhibiting aldosterone secretion, which may result in elevated potassium levels. Hypoglycemia (choice B) is not typically associated with enalapril use. Hypercalcemia (choice C) is also not a common side effect of enalapril. Hypokalemia (choice D) is the opposite of what is expected with enalapril, as it tends to cause potassium retention.

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