Nursing Elites

1. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

• A. Has your son had any immunizations yet?
• B. Is your son sleepy and difficult to feed?
• C. Are you breastfeeding or bottle feeding your son?
• D. Were any relatives born with birth defects?

Correct answer: B

Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.

2. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

• A. Auscultate for renal bruits
• B. Obtain a clean catch mid-stream specimen
• C. Use a dipstick to measure for urinary ketones
• D. Begin to strain the client's urine

Correct answer: B

Rationale: This elderly client is presenting symptoms consistent with a urinary tract infection (UTI), such as confusion, nausea, dysuria, urgency, and incontinence. The best course of action for the nurse is to obtain a clean catch mid-stream specimen. This specimen will help identify the causative agent of the UTI, allowing for targeted treatment with an appropriate anti-infective agent. Auscultating for renal bruits (Choice A) is not indicated in this scenario as the client's symptoms point towards a UTI rather than a renal issue. Using a dipstick to measure for urinary ketones (Choice C) is not relevant in the context of UTI symptoms. Beginning to strain the client's urine (Choice D) would not address the need to identify the causative agent for targeted treatment.

3. A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?

• A. Oatmeal cookies
• B. Cheese sticks
• C. Yogurt
• D. Apple slices

Correct answer: A

Rationale: Oatmeal cookies are the best snack suggestion for a preschooler with constipation needing to increase fiber intake. Oatmeal is high in fiber, which helps relieve constipation. Cheese sticks, yogurt, and apple slices are not as high in fiber content as oatmeal and may not be as effective in addressing the constipation issue in this scenario.

4. Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

• A. Egg whites, toast, and coffee.
• B. Bran muffin, mixed fruits, and orange juice.
• C. Granola and grapefruit juice.
• D. Bagel with jelly and skim milk.

Correct answer: D

Rationale: The correct answer is D, 'Bagel with jelly and skim milk.' This choice includes skim milk, a good source of calcium, which is important for osteoporosis management. It also avoids foods that inhibit calcium absorption. Osteoporosis dietary management emphasizes increased calcium intake and reducing foods that hinder calcium absorption. Choice A only provides proteins but lacks calcium. Choice B offers fruits and a bran muffin, but it lacks a good source of calcium. Choice C has granola but misses a significant source of calcium.

5. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?

• A. 1000 ml
• B. 800 ml
• C. 760 ml
• D. 500 ml

Correct answer: C

Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.

Similar Questions