Nursing Elites

1. Why does the nurse have a 2-year-old boy sit in a “tailor” position while palpating for the presence of the testes?

• A. It prevents the cremasteric reflex
• B. Undescended testes can be palpated
• C. The child has an inguinal hernia
• D. The child does not yet have a need for privacy

Correct answer: A

Rationale: The tailor position stretches the muscle responsible for the cremasteric reflex, preventing it from contracting and pulling the testes into the pelvic cavity. This position helps accurately palpate the testes. Choice B is incorrect because the position does not facilitate the palpation of undescended testes specifically. Choice C is incorrect as it does not relate to the rationale behind the tailor position. Choice D is incorrect as the reason for using the tailor position is not related to the child's need for privacy.

2. A child with acetylsalicylic acid (aspirin) poisoning is being admitted to the emergency department. What early clinical manifestation does the nurse expect to assess on this child?

• A. Hematemesis
• B. Hematochezia
• C. Hyperglycemia
• D. Hyperventilation

Correct answer: D

Rationale: Early signs of aspirin poisoning include hyperventilation due to the stimulation of the respiratory center and the resultant respiratory alkalosis. Hematemesis, hematochezia, and hyperglycemia can occur later in the poisoning process or may not be directly related to aspirin toxicity.

3. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child's mother says she has rubbed the edge of a coin on her child's oiled skin. The nurse should recognize this as what?

• A. Child abuse
• B. Cultural practice to rid the body of disease
• C. Cultural practice to treat enuresis or temper tantrums
• D. Child discipline measure common in the Vietnamese culture

Correct answer: B

Rationale: This practice, known as "coining," is a cultural method believed to rid the body of illness and is not indicative of child abuse.

4. A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?

• A. Restate what the physician has told her about plastic surgery
• B. Suggest holding her baby without making eye contact
• C. Encourage and allow the mother to express her feelings
• D. Recognize and allow the mother to express her feelings

Correct answer: D

Rationale: In this situation, the priority is to acknowledge and validate the mother's feelings, creating a supportive environment for her. Option D is correct as it focuses on recognizing and allowing the mother to express her emotions. This approach can help build trust and facilitate communication. Options A and B are incorrect as they do not address the mother's emotional needs and may come across as dismissive. Option C is less appropriate as it only encourages expression without explicitly recognizing the mother's current emotional state.

5. Chemicals, agents, or factors that cause physical defects in the developing embryo and are most harmful during organogenesis are:

• A. Teratogens
• B. Heterozygous
• C. Inborn errors
• D. Multifactorial

Correct answer: A

Rationale: Teratogens are substances that can cause congenital abnormalities, especially during the first trimester when organogenesis occurs. Choice A, Teratogens, is the correct answer as it specifically refers to substances that cause physical defects in the developing embryo. Choices B, Heterozygous, C, Inborn errors, and D, Multifactorial, are incorrect as they do not directly relate to substances that cause physical defects in embryos during organogenesis.

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