Nursing Elites

1. A child diagnosed with Hepatitis A is under the care of a healthcare provider. Which of the following precautions would be most important to take to prevent the transmission of this infectious disease?

• A. Encourage the Hepatitis A vaccine for family members and siblings
• B. Use needleless systems if possible; otherwise, use careful needle precautionary measures
• C. Teach the child and enforce strict and frequent hand washing
• D. Teach the child and family about the dangers of contaminated food and water

Correct answer: C

Rationale: The most crucial precaution to prevent the transmission of Hepatitis A is to emphasize strict and frequent hand washing. Hepatitis A is a virus that spreads through the oral-fecal route and can survive on human hands. Hand washing is the most effective measure to reduce the risk of transmission. Encouraging the Hepatitis A vaccine for family members and siblings (Choice A) is beneficial for prevention but not as directly impactful as hand washing. While needle precautions (Choice B) are important in healthcare settings, they are not directly relevant to preventing the spread of Hepatitis A. Teaching about the dangers of contaminated food and water (Choice D) is important for general hygiene but may not be as effective as emphasizing hand hygiene in preventing the spread of Hepatitis A.

2. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?

• A. Increase activity level.
• B. Maintain adequate nutrition
• C. Establish a stable environment
• D. Identify sources of hepatitis exposure

Correct answer: B

Rationale: The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.

3. The nurse is creating a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. What is the priority nursing intervention?

• A. Promoting bed rest
• B. Restricting oral fluids
• C. Allowing the child to play
• D. Encouraging visits from friends

Correct answer: A

Rationale: During the acute phase of glomerulonephritis, promoting bed rest is a priority to reduce stress on the kidneys and promote recovery. As the condition improves, activity can be gradually increased. Restricting oral fluids is not recommended as maintaining adequate hydration is crucial. Allowing the child to play quietly can be beneficial but is not the priority over rest during the acute phase. Encouraging visits from friends may disrupt the rest needed for recovery, so visitors should be limited.

4. The parents of a newborn with hypospadias are reviewing the treatment plan with the nurse. Which statement by the parents indicates their understanding of the plan?

• A. Caution should be used when straddling my infant on a hip.
• B. Vital signs should be taken daily to check for bladder infection.
• C. Catheterization will be necessary when my infant does not void.
• D. Circumcision has been delayed to save tissue for surgical repair.

Correct answer: D

Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. It's important not to circumcise the infant, as the dorsal foreskin tissue will be required for surgical repair of the hypospadias. Option A is unrelated to the treatment plan for hypospadias. Option B is not directly related to the surgical repair of hypospadias. Option C is not a routine part of the treatment plan for hypospadias, as catheterization is usually managed by healthcare professionals.

5. What intervention should the nurse implement while a client is having a grand mal seizure?

• A. Open the jaw and place a bite block between the teeth
• B. Try to place the client on his side
• C. Restrain the client to prevent injury
• D. Place pillows around the client

Correct answer: B

Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.

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