Nursing Elites

1. A mother tells the nurse that her 2-year-old toddler has temper tantrums and says 'no' every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development?

• A. Trying to increase independence.
• B. Developing a sense of trust.
• C. Establishing a new identity.
• D. Attempting to master a skill.

Correct answer: A

Rationale: The correct answer is A: Trying to increase independence. Toddlers around the age of 2 often exhibit behaviors like temper tantrums and saying 'no' as they are asserting their independence and autonomy. This behavior is a normal part of their developmental stage where they are starting to explore and assert their own preferences and desires. Choice B, developing a sense of trust, is more relevant to infants during the trust vs. mistrust stage. Choice C, establishing a new identity, is typically associated with adolescence and identity formation. Choice D, attempting to master a skill, is more indicative of a child trying to learn and develop new abilities rather than the behavior described in the scenario.

2. A client has an order for 1000 ml of D5W over an 8-hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?

• A. Ask the client if there are any breathing problems
• B. Have the client void as much as possible
• C. Check the vital signs
• D. Auscultate the lungs

Correct answer: D

Rationale: The correct answer is D: Auscultate the lungs. When a significant amount of fluid has been infused, especially in a short period, it is crucial to assess for signs of fluid overload or pulmonary complications, such as crackles or decreased breath sounds. This can be achieved by auscultating the lungs. Choice A, asking the client about breathing problems, may provide valuable information, but direct assessment through auscultation takes priority. Choice B, having the client void, and Choice C, checking vital signs, are important nursing actions but are not as urgent as assessing the lungs for potential complications in this scenario.

3. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

• A. Ask, 'Tell me more about how your friends discourage you.'
• B. Say, 'Your friends should support you, not discourage you.'
• C. Respond, 'It sounds like your friends are not supportive.'
• D. Suggest, 'You need to focus on your treatment plans regardless of your friends.'

Correct answer: A

Rationale: The correct approach for the nurse is to ask the client to elaborate on how their friends discourage them. By doing so, the nurse shows empathy, encourages the client to express their feelings, and gains insight into the situation. This open-ended question can help the nurse understand the specific issues the client is facing and work towards finding solutions collaboratively. Choices B, C, and D do not effectively address the client's concerns or encourage further discussion. Choice B is directive and may come off as judgmental, choice C assumes the friends are not supportive without exploring further, and choice D dismisses the client's feelings and the impact of peer influence.

4. A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

• A. Establish consistent boundaries for the toddler.
• B. Place the toddler in a room with the door closed.
• C. Inform the toddler how you feel when he misbehaves.
• D. Use a favorite snack to reward the toddler.

Correct answer: A

Rationale: The correct answer is to establish consistent boundaries for the toddler. This approach helps toddlers understand expectations and promotes consistent behavior. Placing the toddler alone or using food rewards may not effectively teach discipline and could be inappropriate. Informing the toddler about feelings when misbehaving may not be developmentally appropriate for a toddler to understand the consequences of their actions.

5. A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?

• A. Request a prescription for an antihypertensive medication.
• B. Ask the client if they are having pain.
• C. Request a prescription for an antianxiety medication.
• D. Return in 30 minutes to recheck the client’s BP.

Correct answer: B

Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.

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