Nursing Elites

1. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

• A. Reassessments
• B. Nursing care provided
• C. Initial assessments
• D. All of the above

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

2. What is the first sign of puberty in boys?

• A. Enlargement of testes
• B. Decreased levels of testosterone
• C. Voice deepening
• D. Pubic hair

Correct answer: A

Rationale: The first sign of puberty in boys is typically the enlargement of the testes. This is due to the increase in production of testosterone, which leads to physical changes such as growth of the testes. Choice B, decreased levels of testosterone, is incorrect as puberty is marked by an increase in testosterone levels. Choice C, voice deepening, and choice D, pubic hair growth, usually occur later in the puberty process compared to testicular enlargement, making them incorrect answers.

3. A major reason for the development of respiratory distress syndrome in the preterm infant is:

• A. Excessive surfactant
• B. Lack of surfactant
• C. Immature immune system
• D. Lack of body fat

Correct answer: B

Rationale: The correct answer is B: Lack of surfactant. Respiratory distress syndrome (RDS) in preterm infants is primarily due to a lack of surfactant, which is crucial for keeping the lungs inflated. Without adequate surfactant, the alveoli collapse, leading to breathing difficulties. Choice A, Excessive surfactant, is incorrect as RDS is caused by an insufficient amount of surfactant. Choice C, Immature immune system, and Choice D, Lack of body fat, are not directly related to the development of respiratory distress syndrome in preterm infants.

4. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.)

• A. Buying clothes for the patients
• B. Showing favoritism toward a patient
• C. All
• D. Spending off-duty time with patients and families

Correct answer: C

Rationale: Overinvolvement includes personal actions like buying clothes, showing favoritism, and spending off-duty time with patients, which can blur professional boundaries.

5. Which are included in the evaluation step of the nursing process? (Select all that apply.)

• A. All below
• B. Ascertaining if the plan requires modification
• C. Determination if the outcome has been met
• D. Selecting alternative interventions if the outcome has not been met

Correct answer: A

Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.

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