Nursing Elites

1. What finding signifies that children have attained the stage of concrete operations according to Piaget?

• A. Demonstrates exploration of the environment through sight and movement
• B. Thinks in mental images or word pictures
• C. Makes the moral judgment that 'stealing is wrong'
• D. Reasons that homework is time-consuming yet necessary

Correct answer: C

Rationale: The correct answer is C, 'Makes the moral judgment that 'stealing is wrong''. This finding signifies the attainment of the concrete operational stage according to Piaget. At this stage, children begin to understand rules and logic, including moral judgments. Choice A is incorrect because it does not specifically relate to concrete operational thinking. Choice B is incorrect as it refers more to the preoperational stage where children engage in symbolic thought. Choice D is also incorrect as it involves practical reasoning, which is not directly related to the concrete operational stage according to Piaget.

2. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

• A. Perform deep palpation at the end of the admission assessment
• B. Auscultate the client’s abdomen before palpation
• C. Begin palpation of the abdomen at the site of pain
• D. Assess the client’s bowel sounds using the bell of the stethoscope

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

3. During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wife’s previous marriage. How should the nurse identify this family form?

• A. Extended
• B. Blended
• C. Nuclear
• D. Alternative

Correct answer: B

Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.

4. A nurse on a med-surg unit is teaching a newly licensed nurse about tasks to delegate to APs. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• A. An AP may take orthostatic blood pressure measurements from a client who reports dizziness.
• B. An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids.
• C. An AP may perform a central line dressing change for a client who is ready for discharge.
• D. An AP may ambulate a client who had a stroke 2 days ago.

Correct answer: D

Rationale: The correct answer is D. Delegating the task of ambulating a client who had a stroke 2 days ago to an AP is appropriate. This task falls within the scope of practice for an AP and can help promote mobility and prevent complications. Choices A, B, and C involve more complex nursing assessments or procedures that require a higher level of training and expertise. Taking orthostatic blood pressure measurements, monitoring a peripheral IV insertion site, and performing a central line dressing change should be tasks performed by licensed nurses to ensure proper assessment and management of the client's condition.

5. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

• A. Troponin level of 0.5 ng/mL
• B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
• C. Serum potassium of 4.5 mEq/L
• D. Blood glucose of 180 mg/dL

Correct answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

Similar Questions