Nursing Elites

1. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?

• A. The young adult is sensitive to criticism.
• B. The young adult verbalizes unrealistic fears.
• C. The young adult verbalizes disappointment with life.
• D. The young adult verbalizes satisfaction with friendships.

Correct answer: D

Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.

2. A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?

• A. The fingers curl tightly, and the toes curl forward.
• B. The toes flare, and the big toe is dorsiflexed.
• C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
• D. The infant turns to the side that is touched.

Correct answer: B

Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.

3. When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?

• A. 1+ edema
• B. 2+ edema
• C. 3+ edema
• D. 4+ edema

Correct answer: C

Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.

4. A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines?

• A. pneumococcal vaccine
• B. hepatitis A vaccine
• C. Lyme disease vaccine
• D. typhoid vaccine

Correct answer: A

Rationale: For a 2-year-old child diagnosed with HIV, in addition to the scheduled vaccines, the nurse should expect to administer the pneumococcal vaccine. Children with HIV are at an increased risk of infections, including pneumococcal disease. The pneumococcal vaccine helps protect against serious pneumococcal infections like pneumonia, meningitis, and bacteremia. The hepatitis A vaccine is not specifically recommended for all children with HIV unless there are specific risk factors. The Lyme disease vaccine is for individuals at risk for Lyme disease, typically between the ages of 15 and 70, transmitted by ticks. The typhoid vaccine is usually recommended for individuals traveling to endemic areas or working in specific high-risk occupations like microbiology laboratories dealing with Salmonella typhi.

5. What type of immunity do vaccines provide?

• A. active
• B. passive
• C. transplacental
• D. active and passive

Correct answer: A

Rationale: Vaccines provide active immunity by stimulating the immune system to produce antibodies against specific pathogens. Choice B, passive immunity, is acquired from ready-made antibodies, not through vaccination. Choice C, transplacental immunity, is a form of passive immunity transferred from mother to infant, not acquired through vaccines. Therefore, the correct answer is active immunity.

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