Nursing Elites

1. When admitting a client, what information should the nurse record in the client’s record first?

• A. Assessment of the client
• B. Client’s medical history
• C. Plan of care
• D. Vital signs

Correct answer: A

Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.

2. A parent is reviewing safety measures for an 8-month-old infant with a nurse. Which of the following statements by the parent indicates an understanding of safety for the infant?

• A. “My baby loved to play with the crib gym, but I took it out of the crib.”
• B. “I just bought a firm mattress so my baby will sleep better.”
• C. “My baby really likes sleeping on the fluffy pillow we just got.”
• D. “I put the baby’s car seat on the table after I put him in it.”

Correct answer: A

Rationale: Choice A is correct because removing the crib gym prevents potential safety hazards such as choking or entrapment. Choices B, C, and D are incorrect as they pose risks to the infant's safety. A firm mattress is recommended for infants to reduce the risk of suffocation. Soft mattresses and fluffy pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby's car seat on a table can lead to falls or other accidents.

3. A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

• A. Establish consistent boundaries for the toddler.
• B. Place the toddler in a room with the door closed.
• C. Inform the toddler how you feel when he misbehaves.
• D. Use a favorite snack to reward the toddler.

Correct answer: A

Rationale: The correct answer is to establish consistent boundaries for the toddler. This approach helps toddlers understand expectations and promotes consistent behavior. Placing the toddler alone or using food rewards may not effectively teach discipline and could be inappropriate. Informing the toddler about feelings when misbehaving may not be developmentally appropriate for a toddler to understand the consequences of their actions.

4. The nurse is caring for an older adult patient diagnosed with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess?

• A. Assess oral cavity.
• B. Assess room for drafts.
• C. Assess ankles for edema.
• D. Assess for reduced sensations.

Correct answer: A

Rationale: The correct answer is to assess the oral cavity. 'Edentulous' means without teeth, so the nurse should assess the oral cavity for any issues related to oral health, dentures, or potential complications. This assessment is crucial to prevent oral health problems and ensure proper care for the patient. Assessing the room for drafts (choice B) is unrelated to the patient's edentulous status and does not address the immediate care needs. Assessing ankles for edema (choice C) is important for circulatory assessment but not directly related to the patient being edentulous. Assessing for reduced sensations (choice D) would be more relevant for neurological or sensory concerns, which are not specifically associated with being edentulous.

5. 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.

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