Nursing Elites

1. The nurse is aware that skin turgor best estimates what?

• A. Perfusion
• B. Adequate hydration
• C. Amount of body fat
• D. Amount of anemia

Correct answer: B

Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.

2. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?

• A. Appropriate because of the child's age
• B. Appropriate, but the mother may be uncomfortable
• C. Inappropriate because of the child's age
• D. Inappropriate because the child is the same sex as the mother

Correct answer: A

Rationale: It is appropriate to give a 10-year-old the choice of having a parent present or not during an exam, respecting the child's growing need for privacy.

3. Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

• A. Face
• B. Buttocks
• C. Oral mucosa
• D. Palms and soles

Correct answer: C

Rationale: The oral mucosa and conjunctivae are the best places to observe petechiae in dark-skinned individuals because these areas have less pigmentation.

4. What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?

• A. Avoid using alkaline-based soap.
• B. Bathe the infant with sterile water.
• C. Cleanse skin with a gentle alkaline-based soap and water.
• D. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.

Correct answer: B

Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.

5. Children may believe that they are responsible for their parents' divorce and interpret the separation as punishment. At which age is this most likely to occur?

• A. 1 year
• B. 4 years
• C. 8 years
• D. 13 years

Correct answer: C

Rationale: At around 8 years old, children may feel they are responsible for their parents' divorce and view it as a punishment, which can impact their emotional well-being.

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