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. A foster parent is talking to the nurse about the health care needs for the child who has been placed in the parent's care. Which statement best describes the health care needs of foster children?

• A. Foster children always come from abusive households and are emotionally fragile.
• B. Foster children tend to have a higher than normal incidence of acute and chronic health problems.
• C. Foster children are usually born prematurely and require technologically advanced health care.
• D. Foster children will not stay in the home for an extended period, so health care needs are not as important as emotional fulfillment.

Correct answer: B

Rationale: Foster children often have higher rates of acute and chronic health problems due to a variety of factors, including previous neglect, trauma, and inconsistent healthcare access.

3. What tool would be most useful to assess maternal and newborn attachment behaviors?

• A. Apgar
• B. Ballard scale
• C. NCAST (Nursing Child Assessment Satellite Training) Feeding Scale
• D. Brazelton Neonatal Behavioral Assessment Scale

Correct answer: C

Rationale: The NCAST Feeding Scale is the most suitable tool to evaluate maternal and newborn attachment behaviors during feedings. It focuses on observing the interaction between the parent and infant, providing insights into their bonding. The Apgar score is used to assess a neonate's immediate transition to life outside the womb, not specifically maternal and newborn attachment behaviors. The Ballard scale is used to estimate gestational age, not to assess attachment behaviors. The Brazelton Neonatal Behavioral Assessment Scale is designed to evaluate a newborn's responses to various stimuli, not specifically maternal and newborn attachment behaviors.

4. In terms of gross motor development, what should the nurse expect an infant age 5 months to do?

• A. Sit erect without support
• B. Roll from the back to the abdomen
• C. Turn from the abdomen to the back
• D. Move from a prone to a sitting position

Correct answer: C

Rationale: At 5 months, infants typically can turn from their abdomen to their back. Rolling from back to abdomen and sitting erect without support occur later.

5. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?

• A. Gently tap over the site.
• B. Apply a cold compress to the site.
• C. Raise the extremity above the level of the body
• D. Use a rubber band as a tourniquet for 5 minutes.

Correct answer: A

Rationale: Gently tapping over the site helps dilate the veins and increase visibility. Applying a cold compress or raising the extremity above the body level constricts the veins, making them harder to access. Prolonged tourniquet use can cause discomfort and venous congestion.

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