Nursing Elites

1. The nurse is discussing toddler development with a parent. Which intervention will foster the achievement of autonomy?

• A. Help the toddler complete tasks
• B. Encourage the toddler to do things for themselves when capable
• C. Provide opportunities for the toddler to play with other children
• D. Help the toddler learn the difference between right and wrong

Correct answer: B

Rationale: Encouraging the toddler to do things for themselves when capable is the correct intervention to foster autonomy. This approach helps the toddler develop independence, self-confidence, and a sense of achievement. Choice A is incorrect as it focuses on assisting rather than encouraging independence. Choice C is incorrect as playing with other children primarily fosters social skills, not necessarily autonomy. Choice D is incorrect as learning the difference between right and wrong is related to moral development, not autonomy.

2. Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?

• A. High serum pH
• B. Normal serum pH
• C. Metabolic alkalosis
• D. Metabolic acidosis

Correct answer: D

Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.

3. A breastfed infant is being seen in the clinic for a 6-month checkup. The mother tells the nurse that the infant recently began to suck her thumb. Which is the best nursing intervention?

• A. Reassure the mother that this is normal at this age
• B. Recommend the mother substitute a pacifier for her thumb
• C. Assess the infant for other signs of sensory deprivation
• D. Suggest the mother breastfeed the infant more often to satisfy her sucking needs

Correct answer: A

Rationale: Thumb sucking is a normal self-soothing behavior in infants and usually does not indicate a problem. Reassuring the mother that this is normal is the appropriate response.

4. Following treatment for iron deficiency anemia, the physician orders lab tests. Which lab value would indicate an improvement in the child’s condition?

• A. Low hemoglobin
• B. Normal platelet count
• C. High reticulocyte count
• D. Low hematocrit

Correct answer: C

Rationale: A high reticulocyte count indicates that the bone marrow is producing more red blood cells, which is a sign of recovery from anemia as the body replenishes its iron stores and increases hemoglobin levels. Low hemoglobin (Choice A) would indicate ongoing anemia rather than improvement. A normal platelet count (Choice B) and low hematocrit (Choice D) are not specific indicators of improvement in iron deficiency anemia.

5. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?

• A. Place a warm moist pack on the scrotal area.
• B. Instruct the adolescent to lie down and elevate the legs.
• C. Refer the adolescent for immediate medical evaluation.
• D. Suggest that the adolescent wear a scrotum-protecting guard.

Correct answer: C

Rationale: Testicular torsion is a surgical emergency requiring immediate medical evaluation. Applying heat or elevating the legs will not alleviate the torsion, and delaying care can lead to testicular necrosis.

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