Nursing Elites

1. At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

• A. Encourage the adolescent to start exercising.
• B. Ask the adolescent to obtain an immediate glucometer reading.
• C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
• D. Tell the adolescent that the prescribed dose of rapid acting insulin should be administered.

Correct answer: D

Rationale: Rapid acting insulin will help lower the elevated blood glucose level quickly.

2. The parents of a 2-year-old child tell the nurse that they are having difficulty disciplining their child. What is the nurse’s most appropriate response?

• A. “This is a difficult age that your child is going through right now.”
• B. “Tell me more about your difficulty. I’m not sure what you mean by this.”
• C. “It’s important to be consistent with toddlers when they need disciplining.”
• D. “I can understand what you mean. That’s why this age is called the terrible twos.”

Correct answer: C

Rationale: The most appropriate response for the nurse is to emphasize the importance of consistency in discipline when dealing with toddlers. Toddlers are at an age where they are learning boundaries and acceptable behaviors. By being consistent, parents can help their child understand what is expected of them and establish a sense of structure and routine. Choices A, B, and D do not provide constructive advice or guidance on how to address the issue of disciplining a 2-year-old. Choice A merely acknowledges the age without providing guidance, choice B seeks more information without offering support, and choice D labels the age without offering practical advice on discipline.

3. What should be included in the teaching plan for parents of an infant diagnosed with phenylketonuria (PKU)?

• A. Mental retardation occurs if PKU is untreated.
• B. Testing for PKU is done immediately after birth.
• C. Treatment for PKU includes lifelong dietary management.
• D. PKU is transmitted as an autosomal recessive trait.

Correct answer: A

Rationale: The correct answer is A: 'Mental retardation occurs if PKU is untreated.' Phenylketonuria (PKU) is a metabolic disorder that results in the inability to metabolize phenylalanine properly. Without proper dietary management, high levels of phenylalanine can lead to severe mental retardation and other neurological problems. Therefore, educating parents about the importance of early and consistent treatment to prevent mental retardation is crucial. Choice B is incorrect because testing for PKU is typically done shortly after birth, not immediately. Choice C is incorrect because treatment for PKU primarily involves strict dietary management to control phenylalanine intake, not lifelong medications. Choice D is incorrect because PKU is inherited in an autosomal recessive pattern, not as an autosomal dominant gene.

4. The healthcare professional is developing a teaching plan for a child who is to have their cast removed. What instruction would the professional most likely include?

• A. Applying petroleum jelly to the dry skin.
• B. Rubbing the skin vigorously to remove the dead skin.
• C. Soaking the area in warm water every day.
• D. Washing the skin with diluted peroxide and water.

Correct answer: C

Rationale: Soaking the area in warm water is the most appropriate instruction for a child who is having their cast removed. This method helps to gently remove dead skin without causing irritation. Applying petroleum jelly to dry skin (Choice A) is not recommended as it may not effectively aid in the removal of dead skin. Rubbing the skin vigorously (Choice B) can lead to skin irritation and should be avoided. Washing the skin with diluted peroxide and water (Choice D) may be too harsh, causing unnecessary irritation to the skin post-cast removal.

5. On the third day of hospitalization, the nurse observes that a 2-year-old toddler who had been screaming and crying inconsolably begins to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?

• A. Denial
• B. Despair
• C. Mistrust
• D. Rejection

Correct answer: B

Rationale: The correct answer is B: Despair. In separation anxiety, the stage of despair is characterized by regression and withdrawal after an initial period of protest. The child may become quiet and appear to accept the separation, but this is actually a sign of deeper distress. Choice A, Denial, is incorrect as it refers to refusing to believe or accept the reality of the separation. Choice C, Mistrust, is incorrect as it pertains to a lack of trust in others, not a stage of separation anxiety. Choice D, Rejection, is incorrect as it involves pushing others away and not related to the described behavior of the toddler in the scenario.

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