Nursing Elites

1. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to:

• A. Reports of difficulty falling and staying asleep
• B. Expression of persistent suicidal thoughts
• C. Lack of enjoyment in usual pleasures
• D. Reduced senses of taste and smell

Correct answer: C

Rationale: The correct answer is C: Lack of enjoyment in usual pleasures. Anhedonia is the inability to feel pleasure in normally pleasurable activities. Choice A, reports of difficulty falling and staying asleep, is more indicative of insomnia rather than anhedonia. Choice B, expression of persistent suicidal thoughts, is related to suicidal ideation and not anhedonia. Choice D, reduced senses of taste and smell, is more associated with disturbances in the sense of taste and smell, not anhedonia.

2. The nurse is assessing a newborn the day after birth. A high-pitched cry, irritability, and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

• A. Reduce the environmental stimuli
• B. Offer formula every 2 hours
• C. Talk to the newborn while feeding
• D. Rock the baby frequently

Correct answer: A

Rationale: The correct intervention is to reduce the environmental stimuli. In this scenario, the newborn is displaying signs of overstimulation and distress, which can be exacerbated by environmental factors. Offering formula every 2 hours (Choice B) may not address the underlying issue of overstimulation. Talking to the newborn while feeding (Choice C) and rocking the baby frequently (Choice D) may further stimulate the newborn, which is not appropriate in this case.

3. When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?

• A. Ensure that adequate mist is supplied
• B. Inspect the nares and ears for skin breakdown
• C. Lubricate the tips of the cannula before insertion
• D. Maintain sterile technique when handling the cannula

Correct answer: B

Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.

4. A pre-term baby develops nasal flaring, cyanosis, and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?

• A. Cardiopulmonary resuscitation
• B. Insertion of a chest tube
• C. Oxygen therapy
• D. Assisted ventilation

Correct answer: B

Rationale: The correct answer is B: Insertion of a chest tube. In a case of spontaneous pneumothorax, the primary intervention is to insert a chest tube. This procedure allows the trapped air to escape from the pleural space, relieving pressure and enabling the lung to re-expand. Choices A, C, and D are not the initial interventions for spontaneous pneumothorax. Cardiopulmonary resuscitation is indicated for cardiac arrest, oxygen therapy may provide supportive care but does not address the underlying issue of trapped air in the pleural space, and assisted ventilation may be needed later but is not the first-line treatment for a pneumothorax.

5. The nurse is caring for a 5-year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?

• A. Kicking balloons with the right leg
• B. Playing 'Simon Says'
• C. Playing handheld games
• D. Throwing bean bags

Correct answer: C

Rationale: Playing handheld games is an appropriate diversional activity for a child in skeletal traction because it does not require physical movement of the affected limb. This activity can help keep the child entertained and engaged without risking any harm to the tractioned leg. Choices A, B, and D involve physical movements that could potentially interfere with the skeletal traction or cause discomfort to the child.

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