Nursing Elites

1. The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?

• A. Peabody Picture Vocabulary Test
• B. The Modified Checklist for Autism in Toddlers (M-CHAT)
• C. Wechsler Preschool and Primary Scale of Intelligence
• D. Denver Developmental Screening Test

Correct answer: B

Rationale: The Modified Checklist for Autism in Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (Choice A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (Choice C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (Choice D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.

2. A client with heart failure is receiving furosemide. What assessment finding indicates the medication is effective?

• A. Increased urine output and weight loss.
• B. Increased heart rate and blood pressure.
• C. Decreased edema and improved peripheral pulses.
• D. Decreased shortness of breath and clear lung sounds.

Correct answer: C

Rationale: The correct answer is C: 'Decreased edema and improved peripheral pulses.' In a client with heart failure, furosemide is a diuretic that helps reduce fluid overload. Therefore, a decrease in edema (swelling due to fluid retention) and improved peripheral pulses (indicating better circulation) are signs that the medication is effective. Choices A, B, and D are incorrect. Increased urine output and weight loss (Choice A) may indicate the diuretic effect of furosemide but do not specifically reflect its effectiveness in heart failure. Increased heart rate and blood pressure (Choice B) are not desired effects of furosemide and may suggest adverse reactions. Decreased shortness of breath and clear lung sounds (Choice D) are related to improved respiratory status and may not directly reflect the effectiveness of furosemide in addressing fluid overload.

3. A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?

• A. Mild impairment
• B. Moderate impairment
• C. Severe impairment
• D. Normal

Correct answer: B

Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring. A GCS score of 10 suggests that the client is moderately impaired neurologically. Choices A, C, and D are incorrect because a GCS score of 10 does not indicate mild impairment, severe impairment, or normal neurological status, respectively.

4. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication ____________.

• A. Can predispose to dysrhythmias
• B. May lead to oliguria
• C. May cause irritability and anxiety
• D. Sometimes alters consciousness

Correct answer: A

Rationale: The correct answer is A: Can predispose to dysrhythmias. Hypokalemia combined with digoxin increases the risk of dysrhythmias due to the potentiation of digoxin's effects on cardiac conduction. Choice B, May lead to oliguria, is incorrect because hypokalemia is not typically associated with oliguria. Choice C, May cause irritability and anxiety, is incorrect as these symptoms are more commonly associated with hypocalcemia. Choice D, Sometimes alters consciousness, is incorrect as altered consciousness is not a typical effect of hypokalemia combined with digoxin.

5. A female client experiences a sudden loss of consciousness and is taken to the emergency department. Initial assessment indicates her blood glucose level is critically low. Once stabilized, she reports being treated for anorexia nervosa. What intervention is most important for the nurse to include in the client’s discharge plan?

• A. Encourage a high-protein, low-carbohydrate diet.
• B. Encourage her to join a group focusing on self-esteem.
• C. Schedule an outpatient psychosocial assessment.
• D. Teach relaxation techniques to manage stress.

Correct answer: B

Rationale: Joining a group that focuses on self-esteem is the most important intervention for the nurse to include in the client's discharge plan. This can help the client address underlying emotional issues related to her anorexia nervosa and improve her mental health. Choice A is incorrect because a high-protein, low-carbohydrate diet may not address the psychological factors contributing to anorexia nervosa. Choice C is incorrect as scheduling an outpatient psychosocial assessment is important but not the most crucial intervention for discharge planning in this case. Choice D is also not the priority as teaching relaxation techniques, although beneficial, may not directly address the self-esteem and emotional issues that need to be tackled in this situation.

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