Nursing Elites

1. When a woman is having her first child, she is experiencing which type of crisis event?

• A. situational
• B. maturational
• C. adventitious
• D. reactive

Correct answer: B

Rationale: A maturational crisis occurs when an individual reaches a new stage of development, such as becoming a parent for the first time, and needs to develop new coping strategies to adapt to this change. Situational crises (Choice A) arise from external sources, not developmental milestones. Adventitious crises (Choice C) are caused by external events like natural disasters and are not related to personal development stages. Reactive crises (Choice D) are responses to specific stressors and are not associated with developmental milestones like becoming a parent for the first time.

2. The client with schizophrenia has become disruptive and requires seclusion. Which staff member can institute seclusion?

• A. The security guard
• B. The registered nurse
• C. The licensed practical nurse
• D. The nursing assistant

Correct answer: B

Rationale: The registered nurse is the correct choice to institute seclusion for a client with schizophrenia. In healthcare settings, only a registered nurse or a physician can legally initiate seclusion. The security guard, licensed practical nurse, and nursing assistant do not have the authority to carry out this action. Therefore, options A, C, and D are incorrect.

3. A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:

• A. is pregnant.
• B. is immunocompromised.
• C. is allergic to neomycin.
• D. has a cold.

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold. A simple cold without fever does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine due to the live rubella component, which may lead to birth defects or disease. Choice C is incorrect because individuals with anaphylactic reactions to neomycin should not receive the measles vaccine according to the American Academy of Pediatrics.

4. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

• A. "She is very irritable lately."?
• B. "She sleeps quite a bit of the time."?
• C. "Her gums look too big for her teeth."?
• D. "She has gained about 10 pounds in the last 6 months."?

Correct answer: C

Rationale: The correct answer is '"Her gums look too big for her teeth."?' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '"She is very irritable lately,"?' is not a typical side effect of Dilantin. Option B, '"She sleeps quite a bit of the time,"?' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '"She has gained about 10 pounds in the last 6 months,"?' is not typically associated with Dilantin therapy and is unrelated to the question.

5. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:

• A. feelings about what has been described
• B. thoughts about what has been described
• C. possible solutions to the problem
• D. intent in sharing the description

Correct answer: B

Rationale: In a psychosocial assessment, the nurse should progress from having the client describe problematic behaviors to eliciting their thoughts about the dilemmas. This step provides essential assessment data and insights into the client's interpretation of the situation. Asking about feelings, solutions, or intent in sharing the description is premature at this stage. Understanding the client's thoughts is crucial before delving into more complex emotional or problem-solving aspects. Therefore, the correct answer is to elicit the client's thoughts about the described behaviors and situations, as this helps the nurse gain a deeper understanding of the client's perspective and thought processes.

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