Nursing Elites

1. During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?

• A. Document these measurements in the infant's health care record.
• B. Tell the mother that the infant is growing faster than expected.
• C. Suggest to the health care provider that a skull x-ray be performed.
• D. Report the presence of hydrocephalus to the health care provider.

Correct answer: A

Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.

2. When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?

• A. Sex role identification begins in infancy.
• B. Sex role identification begins in the preschool years.
• C. Sex role identification begins during the school-age years.
• D. Sex role identification begins during early adolescence.

Correct answer: A

Rationale: Sex role identification begins during infancy as infants can identify body parts by the end of the first year. Preschoolers often engage in masturbation and sex play. School-age children continue to develop awareness of their sexual identity, including behaviors like hugging and kissing. Early adolescence sees further development influenced by sexual maturation and experimentation with sex roles. Therefore, the correct statement is that sex role identification begins in infancy. Choices B, C, and D are incorrect as they misrepresent the timeline of the development of sex role identification in children.

3. When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:

• A. "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes."?
• B. "If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age."?
• C. "When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch."?
• D. "You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time."?

Correct answer: A

Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.

4. A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

• A. The client has a fever.
• B. The skin temperature is normal.
• C. The client needs to drink additional fluids.
• D. The client needs to have the blanket removed.

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

5. The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother?

• A. Infection always occurs when body piercing is done
• B. Hepatitis B is a concern with body piercing
• C. Body piercing is generally harmless as long as it is performed under sterile conditions
• D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)

Correct answer: C

Rationale: Generally, body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some complications that may occur include bleeding, infection, keloid formation, and the development of allergies to metal. It is essential to clean the area at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not typically associated with body piercing; however, they are a possibility with tattooing. Choice A is incorrect because infection does not always occur when body piercing is done. Choice B is not the best answer as hepatitis B is not commonly associated with body piercing. Choice D is incorrect because the risk of contracting HIV is not a significant concern with body piercing if performed under sterile conditions.

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