Nursing Elites

1. When working with a couple at risk of bearing a child with a genetic abnormality, what is most important for the nurse to incorporate into the plan of care?

• A. Gathering information from at least three generations
• B. Informing the couple of the need for a wide range of information
• C. Maintaining the confidentiality of the information
• D. Presenting the information in a nondirective manner

Correct answer: D

Rationale: When counseling a couple at risk of genetic abnormalities, it is crucial to present information in a nondirective manner. This approach allows the couple to make informed decisions without feeling pressured or influenced. Gathering information from at least three generations (Choice A) may be relevant for genetic counseling but is not the most critical aspect in this scenario. Informing the couple of the need for a wide range of information (Choice B) is too general and does not address the specific approach needed in this situation. Maintaining the confidentiality of the information (Choice C) is important but not the top priority compared to presenting information in a nondirective manner.

2. A 3-year-old child ingests a substance that may be a poison. The parent calls a neighbor who is a nurse and asks what to do. What should the nurse recommend the parent do?

• A. Administer syrup of ipecac.
• B. Call the poison control center.
• C. Take the child to the emergency department.
• D. Give the child bread dipped in milk to absorb the poison.

Correct answer: B

Rationale: In cases of potential poisoning, the best immediate action to take is to call the poison control center. Administering syrup of ipecac is no longer recommended as it can lead to complications such as aspiration and may interfere with subsequent treatments. Taking the child to the emergency department should only be done if advised by the poison control center or if the child is showing severe symptoms. Giving bread dipped in milk to absorb the poison is not an appropriate or effective treatment for poisoning, as it does not address the toxicity of the ingested substance and may delay appropriate medical interventions.

3. A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse explain is the most important factor in the process of toilet training?

• A. Parents’ attitude towards it
• B. Child’s motivation to remain dry
• C. Child’s ability to sit independently on the toilet
• D. Parents’ commitment to work on the toilet training

Correct answer: D

Rationale: The most crucial factor in successful toilet training is the parents' commitment to consistently work with their child. While parents' attitude and willingness are important, the key is their dedication to the process. The child's motivation and ability are also significant but rely heavily on parental guidance and support. Therefore, the correct choice is the parents' commitment to work on toilet training.

4. The nurse is teaching a group of parents about the side effects of immunization vaccines. Which sign should the nurse include when discussing an infant receiving the Haemophilus influenzae (Hib) vaccine?

• A. Lethargy
• B. Urticaria
• C. Generalized rash
• D. Low-grade fever

Correct answer: D

Rationale: The correct answer is 'D. Low-grade fever.' A low-grade fever is a common and mild side effect of the Hib vaccine, indicating that the immune system is responding to the immunization. Lethargy (choice A) can be a sign of more serious adverse effects and should be monitored closely but is not typically associated with the Hib vaccine. Urticaria (choice B) and generalized rash (choice C) are less common side effects of the Hib vaccine compared to low-grade fever.

5. During a routine monthly examination, a 5-month-old infant is brought to the pediatric clinic. What assessment finding should alert the nurse to notify the health care provider immediately?

• A. Temperature of 99.5°F
• B. Blood pressure of 75/48 mm Hg
• C. Heart rate of 100 beats per minute
• D. Respiratory rate of 50 breaths per minute

Correct answer: D

Rationale: A respiratory rate of 50 breaths per minute in a 5-month-old infant is higher than the expected range and may indicate respiratory distress. This finding is concerning and should prompt the nurse to notify the health care provider for further evaluation and intervention. A temperature of 99.5°F, blood pressure of 75/48 mm Hg, and heart rate of 100 beats per minute are within normal ranges for a 5-month-old infant. Elevated temperature may indicate a mild fever, which can be monitored. A blood pressure of 75/48 mm Hg is within the normal range for infants. A heart rate of 100 beats per minute is also within the expected range for a 5-month-old infant and does not typically require immediate notification of the health care provider.

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