Nursing Elites

1. Around what age do children typically start to develop 'stranger anxiety'?

• A. 9 months
• B. 6 months
• C. 3 months
• D. 12 months

Correct answer: B

Rationale: The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.

2. When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except:

• A. some Hispanic and Native-American cultures are very open when discussing sexuality.
• B. some cultures view the postpartum period as a state of impurity.
• C. some women in the African-American culture view childbearing as a validation of their femaleness.
• D. some Native-American women believe monthly menstruation maintains physical well-being and harmony.

Correct answer: A

Rationale: When working with multicultural populations, it is essential to understand cultural variations in beliefs and practices related to sexuality. While it is true that some cultures view the postpartum period as a state of impurity and that some women in the African-American culture view childbearing as a validation of their femaleness, the statement 'some Hispanic and Native-American cultures are very open when discussing sexuality' is incorrect. In reality, many cultures, including Hispanic and Native-American cultures, are sometimes hesitant to discuss sexuality. For example, some Navajos, Hispanics, and Orthodox Jews may consider the postpartum period as impure, leading to seclusion of women until the end of bleeding, marked by a ritual bath. Additionally, many Native-American women believe in the importance of monthly menstruation for physical well-being and harmony. Therefore, the statement about Hispanic and Native-American cultures being very open about discussing sexuality is not accurate in the context of working with multicultural populations.

3. A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?

• A. The procedure typically takes 10 to 30 minutes.
• B. She may need to drink fluids before the test and may not void until the test has been completed.
• C. A probe coated with gel will be inserted into the vagina.
• D. She will be positioned on her back, with her head elevated and turned slightly to one side.

Correct answer: B

Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.

4. An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?

• A. emotional support to help the family cope with feelings of guilt about the infant's condition
• B. administration of MICRhoGam to the woman within 72 hours of delivery
• C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
• D. lab analysis of maternal Direct Coombs' test

Correct answer: A

Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs' test (Choice D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.

5. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

• A. Loss of hearing acuity
• B. A problem with balance
• C. A problem with distant hearing
• D. A problem discriminating high-pitched and low-pitched sounds

Correct answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

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