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. The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?

• A. 150 mL/hour
• B. 250 mL/hour
• C. 50 mL/hour
• D. 275 mL/hour

Correct answer: A

Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. The IV bag contains 20 grams of magnesium sulfate in 500 mL of solution, which means there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. Choice B, 250 mL/hour, is incorrect because it miscalculates the amount of magnesium sulfate infused per hour. Choice C, 50 mL/hour, is incorrect as it is too slow to deliver the required dose in the specified time frame. Choice D, 275 mL/hour, is incorrect as it overestimates the infusion rate and would deliver the dose too quickly.

3. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in the client's nursing care plan?

• A. Assess temperature every hour.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations every 4 hours.
• D. Keep an airway at the bedside.

Correct answer: D

Rationale: In the case of eclampsia, the priority intervention is to keep an airway at the bedside. Eclampsia is associated with a high risk of convulsions, and having an airway readily available is crucial for prompt intervention in the event of seizures. Assessing temperature, allowing family visitation, and monitoring vital signs are important aspects of care but ensuring airway patency takes precedence in this situation to manage potential complications and ensure the client's safety.

4. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

• A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
• B. The chorea or movements are temporary and will eventually disappear.
• C. Permanent lifestyle changes are not needed to promote safety in the home.
• D. Consistent discipline is not directly related to controlling the movements.

Correct answer: B

Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course. Choices A, C, and D are incorrect because muscle tension, permanent lifestyle changes, and consistent discipline are not directly related to the resolution of chorea in rheumatic fever.

5. A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?

• A. Use an alternative form of contraception until a new diaphragm is obtained.
• B. After weaning, the diaphragm should be resized.
• C. Avoid intercourse during ovulation until the diaphragm size is reassessed.
• D. If weight gain during pregnancy was no more than 20 pounds, the diaphragm is safe to use.

Correct answer: A

Rationale: The nurse should advise the client to use an alternative form of contraception until a new diaphragm that fits correctly post-pregnancy is obtained. It is essential to ensure proper fit for effective contraception, making it crucial to use an alternative method until the diaphragm is resized.

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