Nursing Elites

1. The nurse is planning care for a 4-year-old girl diagnosed with a developmental disability. What should be the primary focus of treatment for this child?

• A. Teach her social skills.
• B. Assist in preventing further disability.
• C. Ensure her participation in group activities.
• D. Help her achieve her maximum potential.

Correct answer: D

Rationale: The primary focus of treatment for a child diagnosed with a developmental disability should be helping them achieve their maximum potential. This approach aims to optimize the child's physical, emotional, cognitive, and social abilities, focusing on enhancing their overall well-being and quality of life. By supporting the child in reaching their highest level of functioning, caregivers can promote independence, self-esteem, and personal growth, which are essential components of holistic care for individuals with developmental disabilities. Teaching social skills (choice A) is important but is just one aspect of the comprehensive care needed. Preventing further disability (choice B) may not always be entirely achievable, but maximizing potential is a more realistic goal. Ensuring participation in group activities (choice C) is valuable for social development, but the primary focus should be on overall potential and well-being.

2. Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child’s plan of care?

• A. Monitor serum glucose for adjustment in the infusion rate of regular insulin (Novolin R).
• B. Determine the child’s compliance schedule for subcutaneous NPH insulin (Humulin N).
• C. Demonstrate to the parents how to program an insulin pen for daily glucose regulation.
• D. Consult with the healthcare provider about the use of insulin detemir (Levemir Flex Pen).

Correct answer: A

Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA. Choice B is incorrect as it focuses on a different type of insulin and compliance schedule without addressing the immediate needs of managing DKA. Choice C is not the priority action and involves educating parents on a different method of insulin administration. Choice D is also not the most important action as it suggests consulting with the healthcare provider about a different type of insulin rather than focusing on immediate glucose monitoring for insulin adjustment in DKA management.

3. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

• A. Patellar reflex 4+
• B. Blood pressure 158/80
• C. Four-hour urine output 240 ml
• D. Respirations 12/minute

Correct answer: A

Rationale: The correct answer is A: 'Patellar reflex 4+'. Hyperreflexia is a sign of severe preeclampsia and increases the risk of seizures, indicating the need for immediate intervention. Monitoring and addressing this finding are crucial in managing the client's condition and preventing complications.

4. A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

• A. 4+ reflexes
• B. Urinary output of 50 ml per hour
• C. A decrease in respiratory rate from 24 to 16
• D. A decreased body temperature

Correct answer: C

Rationale: A decrease in respiratory rate from 24 to 16 indicates that magnesium sulfate is effectively reducing central nervous system irritability, a desired therapeutic effect. This decrease in respiratory rate signifies that the drug has reached a therapeutic level to control symptoms of severe pregnancy-induced hypertension. Choices A, B, and D are incorrect because 4+ reflexes, urinary output, and body temperature are not direct indicators of achieving a therapeutic level of magnesium sulfate for controlling PIH symptoms.

5. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

• A. Obtain blood culture.
• B. Administer penicillin.
• C. Cover lesion with a dressing.
• D. Prepare her for cesarean section.

Correct answer: D

Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.

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