Nursing Elites

1. The parents of a 2-year-old child ask the nurse how they can teach their child to stop taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child's behavior?

• A. "Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys."?
• B. "Your child is showing negativity. He doesn't want other children to have the toys he wants."?
• C. "Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys."?
• D. "Your child is engaging in domestic imitation. He is doing what he has seen other children do."?

Correct answer: A

Rationale: Two-year-old children are very egocentric, believing everything revolves around them. They think other children want them to have their toys, which explains why they may take toys from others. This behavior is typical for children at this age as they lack the ability to see things from another's perspective. Option B is incorrect because negativity in children this age is more related to refusal of requests rather than taking toys. Magical thinking, as described in option C, is usually seen in preschool-age children and involves unrealistic beliefs. Option D is incorrect as domestic imitation refers to imitating adult household tasks, not other children's behavior.

2. A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?

• A. The procedure typically takes 10 to 30 minutes.
• B. She may need to drink fluids before the test and may not void until the test has been completed.
• C. A probe coated with gel will be inserted into the vagina.
• D. She will be positioned on her back, with her head elevated and turned slightly to one side.

Correct answer: B

Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.

3. A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?

• A. Asking the client to raise their eyebrows and looking for symmetry
• B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle
• C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face
• D. Asking the client to close their eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear

Correct answer: D

Rationale: To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing. Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).

4. Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.

• A. plug the patient to the ECG Monitor
• B. Administer the medication over at least 5 minutes.
• C. Monitor respirations during administration.
• D. Monitor the client's pulse for 1 minute prior to administration.

Correct answer: D

Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client's pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.

5. When testing the function of the oculomotor, trochlear, and abducens nerves, which parameter does a nurse check to determine their function?

• A. Tongue symmetry
• B. Eye movements
• C. Facial symmetry
• D. Corneal reflex

Correct answer: B

Rationale: The correct answer is B: Eye movements. When assessing the oculomotor, trochlear, and abducens nerves, evaluating eye movements is crucial. This assessment includes checking the pupils for size, regularity, equality, light reactions, accommodation, and extraocular movements in various gaze positions. Tongue symmetry is primarily used to evaluate cranial nerve XII (hypoglossal nerve) function. Facial symmetry is a key indicator of cranial nerve VII (facial nerve) function. The corneal reflex assesses sensory afferents in cranial nerve V (trigeminal nerve) and motor efferents in cranial nerve VII (facial nerve).

Similar Questions