Nursing Elites

1. A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?

• A. The immune system of an infant is immature, and the infant is at risk for infection.
• B. The transfer of your antibodies protects your infant until the infant is 12 months old.
• C. Yes, your infant is protected from all infections.
• D. If you breastfeed, your infant is protected from infection.

Correct answer: A

Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.

2. The client asks the nurse not to tell anyone outside of the care team about his positive HIV diagnosis. What response is most appropriate?

• A. "I have to inform all clients on the unit of your diagnosis as it is transmissible."?
• B. "I will not communicate your diagnosis to anyone without your permission."?
• C. "Because this is a communicable disease, it may need to be reported to the CDC."?
• D. "You should not be concerned with who I share your diagnosis with."?

Correct answer: C

Rationale: The most appropriate response is C: "Because this is a communicable disease, it may need to be reported to the CDC."? It is important to uphold patient confidentiality, but in the case of certain communicable diseases like HIV, there are legal requirements for mandatory reporting to public health authorities such as the CDC. Option A is incorrect because it violates patient confidentiality and does not consider legal obligations. Option B, while respecting the client's wishes, may not align with the legal requirement for reporting certain communicable diseases. Option D is inappropriate as it dismisses the client's concerns and rights regarding their health information.

3. A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately take which action?

• A. Refuse to do the assignment
• B. Tell the nurse manager to call the nursing supervisor
• C. Return to the medical care unit and discuss the assignment with the nurse manager on that unit
• D. Ask the nurse manager of the intensive care unit to discuss the assignment

Correct answer: D

Rationale: In this scenario, the nurse feeling that the assignment is more difficult than what other nurses received should approach the nurse manager of the intensive care unit to discuss the assignment. By doing so, the nurse can seek clarification on the rationale for the assignment or confirm if it is genuinely more challenging. Refusing the assignment is not appropriate as it could impact patient care. Returning to the medical care unit would be considered client abandonment and does not directly address the conflict at hand. Instructing the nurse manager to involve the nursing supervisor is an aggressive approach that does not directly resolve the issue.

4. Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs?

• A. epilepsy
• B. Parkinson's
• C. multiple sclerosis
• D. Huntington's chorea

Correct answer: D

Rationale: Huntington's chorea is characterized by writhing, twisting movements of the face and limbs, known as chorea. This disorder is caused by a genetic mutation affecting specific brain cells. Epilepsy presents with seizures, Parkinson's with tremors and rigidity, and multiple sclerosis with central nervous system issues. The specific description of writhing and twisting movements aligns with Huntington's chorea, making it the correct answer. Choices A, B, and C are incorrect as they describe different neurological disorders with distinct symptoms that do not match the writhing, twisting movements characteristic of Huntington's chorea.

5. A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up?

• A. A client who exhibits signs of increased intracranial pressure after a craniotomy.
• B. A client who has sustained a stroke and dresses herself.
• C. A client with a spinal cord injury transfers himself from a bed to a wheelchair.
• D. Normal neurological findings are noted in a client with a cerebral aneurysm.

Correct answer: A

Rationale: A case manager is responsible for coordinating a client's care and monitoring for unexpected outcomes. The situation that indicates an unexpected outcome and the need for immediate follow-up is when a client exhibits signs of increased intracranial pressure after a craniotomy. This indicates a deteriorating condition that requires urgent intervention. Choices B, C, and D describe expected outcomes or normal findings related to specific conditions, which do not demand immediate follow-up.

Similar Questions