Nursing Elites

1. A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?

• A. Initiate cardiopulmonary resuscitation
• B. Gently stimulate the infant by rubbing his back while administering oxygen
• C. Recheck the score in 5 minutes
• D. Provide no action except to support the infant's spontaneous efforts

Correct answer: B

Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.

2. A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

• A. Headache
• B. Neck trauma
• C. Sinus infection
• D. Muscle spasms

Correct answer: B

Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.

3. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?

• A. lettuce
• B. eggs
• C. chocolate
• D. butterscotch

Correct answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce, eggs, and butterscotch do not affect LES pressure and are less likely to trigger heartburn in individuals with GERD. Therefore, clients who are prone to developing heartburn due to GERD should avoid consuming chocolate to manage their symptoms effectively.

4. The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?

• A. slow speech development
• B. overreaction to stimuli from the surroundings
• C. inability to carry on a conversation
• D. concrete thinking

Correct answer: B

Rationale: The correct answer is 'overreaction to stimuli from the surroundings.' Children with attention deficit disorder often exhibit hypersensitivity to stimuli, leading to overreactions. Slow speech development is not a hallmark of attention deficit disorder; it is more associated with other learning disabilities. While children with this disorder may have difficulty focusing, they can usually carry on a conversation. Concrete thinking is not a common characteristic of attention deficit disorder, as individuals with this disorder may struggle with abstract thinking and impulsivity.

5. When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?

• A. Sex role identification begins in infancy.
• B. Sex role identification begins in the preschool years.
• C. Sex role identification begins during the school-age years.
• D. Sex role identification begins during early adolescence.

Correct answer: A

Rationale: Sex role identification begins during infancy as infants can identify body parts by the end of the first year. Preschoolers often engage in masturbation and sex play. School-age children continue to develop awareness of their sexual identity, including behaviors like hugging and kissing. Early adolescence sees further development influenced by sexual maturation and experimentation with sex roles. Therefore, the correct statement is that sex role identification begins in infancy. Choices B, C, and D are incorrect as they misrepresent the timeline of the development of sex role identification in children.

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