Nursing Elites

1. A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?

• A. Primary
• B. Secondary
• C. Tertiary
• D. Health promotion

Correct answer: A

Rationale: Primary prevention involves activities that promote wellness or prevent illness or injury. Educating parents about safety measures in the home aims to prevent injuries, making it a primary prevention strategy. Secondary prevention focuses on early detection and intervention in diseases or injuries. Tertiary prevention involves reducing disability and promoting optimal functioning in relation to a disease or injury. Health promotion encompasses activities that enhance a client's overall health and well-being. In this scenario, educating parents about safety in the home falls under primary prevention as it aims to prevent injuries before they occur.

2. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

3. The client has been on vancomycin for three days. Which of the following symptoms is least concerning?

• A. nausea
• B. headache
• C. vertigo
• D. tinnitus

Correct answer: B

Rationale: The correct answer is 'headache.' While vancomycin can cause ototoxicity leading to symptoms like tinnitus, vertigo, and nausea, headaches are not typically associated with vancomycin use. Therefore, headache is the least concerning symptom in this scenario. Nausea, vertigo, and tinnitus are more likely to be related to vancomycin ototoxicity and should be closely monitored and reported. Headache is a common symptom that may not be directly linked to vancomycin use.

4. An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?

• A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
• B. Checking the amniotic fluid for intrauterine infection
• C. Determination of fetal lung maturity
• D. Checking the fetal cells for chromosomal abnormalities

Correct answer: C

Rationale: The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.

5. The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?

• A. She prefers crawling over walking and makes no attempt to walk.
• B. She seems distressed by new adults.
• C. She does not respond to her own name.
• D. She only babbles "mama"? and "dada."?

Correct answer: C

Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.

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