Nursing Elites

1. Children with cerebral palsy, Down syndrome, and intellectual disabilities are likely to have abnormal sensory input and muscle tone. A small, underdeveloped tongue is common in many such disorders and results in diminished nutritional status.

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true; the second is false
• D. The first statement is false; the second is true

Correct answer: C

Rationale: The first statement is true, but the second is false. These children often have a large tongue or tongue thrust, which can interfere with feeding and nutrition.

2. A patient tells the nurse “I am depressed to talk to you, leave me alone” Which of the following response by the nurse is most therapeutic?

• A. I’ll be back in an hour
• B. Why are you so depressed?
• C. I’ll seat with you for a moment
• D. Call me when you feel like talking to me

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. During the detoxification stage, it is a priority for the nurse to:

• A. teach skills to recognize and respond to health threatening situations
• B. increase the client’s awareness of unsatisfactory protective behaviors
• C. implement behavior modification
• D. promote homeostasis and minimize the client’s withdrawal symptoms

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. Which of the following actions would be of highest priority with regards to the external shunt?

• A. Avoid taking blood pressure or blood sample from the arm with the shunt
• B. Instruct the patient not to exercise the arm with the shunt
• C. Heparinize the shunt daily
• D. Change the dressing of the shunt daily

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

5. Which condition is an example of a potential cause of gastritis?

• A. bile reflux
• B. low salt intake
• C. hypophosphatasia
• D. gallstones

Correct answer: A

Rationale: Bile reflux is a potential cause of gastritis as it can irritate the stomach lining when bile backs up into the stomach. Choices B, C, and D do not directly cause gastritis. Low salt intake is not a common cause of gastritis. Hypophosphatasia is a rare genetic disorder affecting bone development, not the stomach. Gallstones, while related to the gallbladder, are not a direct cause of gastritis.

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