Nursing Elites

1. Which of the following infant behaviors demonstrates the concept of object permanence?

• A. The infant cries when his mother leaves the room.
• B. The infant looks at the floor to find a toy that he was playing with and dropped.
• C. The infant picks up another toy after the one he was playing with rolls under the couch.
• D. The infant participates in a game of patty-cake.

Correct answer: B

Rationale: Object permanence occurs when the infant learns that something or someone still exists even though they might not be able to see it or them. This typically develops between 9 and 10 months of age. The correct answer, 'The infant looks at the floor to find a toy that he was playing with and dropped,' demonstrates object permanence as the infant understands that the toy still exists even though it is temporarily out of sight. Choices A and C do not directly relate to object permanence as the behaviors described do not necessarily indicate an understanding of objects existing when out of sight. Choice D is incorrect as participating in a game of patty-cake does not involve demonstrating object permanence. Peek-a-boo is a more suitable example of a game that demonstrates object permanence, as the infant continues to look for the hidden face, understanding that it still exists even though temporarily unseen.

2. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

• A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
• B. Hold medications and notify the physician
• C. Arouse the client and give some orange juice with sugar packets added
• D. Give the medications as ordered and re-check blood sugar in one hour

Correct answer: A

Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.

3. Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?

• A. open leg fracture
• B. open head injury
• C. stab wound to the chest
• D. traumatic amputation of a thumb

Correct answer: C

Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. In this scenario, the stab wound to the chest poses the highest risk to the client's life as it can lead to severe complications such as lung collapse and mediastinal shift. Addressing this injury promptly is crucial to prevent further harm or potential fatality. Open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate life-threatening risk compared to a stab wound to the chest.

4. A healthcare professional is assessing a patient's right lower extremity. The extremity is warm to touch, red, and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?

• A. Herpes
• B. Scleroderma
• C. Dermatitis
• D. Cellulitis

Correct answer: D

Rationale: The patient's presentation of a warm, red, swollen extremity with a low fever is indicative of cellulitis, which is inflammation of cellular tissue. Cellulitis is commonly associated with these symptoms due to a bacterial infection in the skin and underlying tissues. Herpes (Choice A) is a viral infection that typically presents with grouped vesicles, not the warm, red, swollen presentation seen in cellulitis. Scleroderma (Choice B) is a chronic autoimmune condition affecting the skin and connective tissue, presenting differently from the acute symptoms of cellulitis. Dermatitis (Choice C) refers to skin inflammation, which does not typically present with the described symptoms of warmth, redness, swelling, and low fever observed in cellulitis.

5. During the admission assessment for a client undergoing breast augmentation, which information should the nurse prioritize reporting to the surgeon before surgery?

• A. The client is concerned about who will care for her two children while she recovers.
• B. The client has a history of postoperative dehiscence after a previous C-section.
• C. The client's statement that her last menstrual period was 8 weeks prior.
• D. The client's concerns over pain control postoperatively.

Correct answer: C

Rationale: The most important information for the nurse to report to the surgeon before surgery is the client's statement that her last menstrual period was 8 weeks prior. This information is crucial as the client may be pregnant, and a pregnancy test will need to be completed before administering any anesthetic agents. Reporting this detail ensures patient safety and prevents potential risks associated with anesthesia. Choices A, B, and D are important aspects of care but do not take precedence over the need to rule out pregnancy before surgery.

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