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. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?

• A. Headache
• B. Prothrombin time (PT) of 15 seconds
• C. Elevated liver enzymes
• D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.

3. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?

• A. Support the client by praising her progress.
• B. Ask the client if she has had any recent thoughts of harming herself.
• C. Reassure the client about the effectiveness of antidepressant drugs.
• D. Advise the client to keep her belongings for discharge.

Correct answer: B

Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.

4. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

• A. Expresses an understanding of the procedure.
• B. NPO for 6 hrs.
• C. No known drug allergies.
• D. Intravenous access intact.

Correct answer: A

Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which laboratory value requires immediate intervention?

• A. Arterial blood gas (ABG) values
• B. Serum potassium level
• C. Serum sodium level
• D. Blood glucose level

Correct answer: A

Rationale: The correct answer is A: Arterial blood gas (ABG) values. In a client with COPD and pneumonia, ABG values are crucial as they provide essential information about the client's respiratory status, including oxygenation and acid-base balance. Immediate intervention may be required to optimize respiratory function based on ABG results. Serum potassium, sodium, and blood glucose levels are important parameters to monitor in various conditions but are not as directly related to the respiratory status in a client with COPD and pneumonia. Therefore, they do not require immediate intervention compared to ABG values.

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