Nursing Elites

1. What side effect should the nurse include in the parent teaching for a child prescribed a baclofen pump for cerebral palsy?

• A. Diarrhea
• B. Hypertonia
• C. Hypotonia
• D. Restlessness

Correct answer: C

Rationale: When a child is prescribed a baclofen pump for cerebral palsy, one of the common side effects to include in parent teaching is hypotonia. Baclofen, a muscle relaxant, can lead to decreased muscle tone, resulting in hypotonia. It is important for parents to be aware of this potential side effect and know how to respond accordingly.

2. Which of the following is a key feature of the diagnosis of ASD according to the DSM V?

• A. Unusual responses to sensory input
• B. Social isolation
• C. Repetitive behaviors
• D. Delayed motor development

Correct answer: A

Rationale: In the DSM V, one of the key diagnostic criteria for Autism Spectrum Disorder (ASD) is unusual responses to sensory input. These atypical responses can include hypersensitivity or hyposensitivity to sensory stimuli, such as sound, touch, taste, or smell. These sensory processing differences are important in the diagnosis of ASD because they can significantly impact an individual's daily functioning and behavior. Social isolation and repetitive behaviors are associated features of ASD but are not the key diagnostic criteria according to the DSM V. Delayed motor development may be observed in some individuals with ASD, but it is not a key feature used for diagnosis in the DSM V.

3. The patient taking warfarin for prevention of deep vein thrombosis has an INR of 1.2. Which action by the nurse is most appropriate?

• A. Administer IV push protamine sulfate
• B. Continue with the current prescription.
• C. Prepare to administer Vitamin K
• D. Call healthcare provider to increase the dose

Correct answer: D

Rationale: An INR level of 1.2 is below the therapeutic range (2-3) for warfarin therapy. Therefore, the nurse should contact the healthcare provider to discuss the need for an increased dose to achieve the desired therapeutic range and prevent deep vein thrombosis effectively. Administering IV push protamine sulfate is used to reverse the effects of heparin, not warfarin. Continuing with the current prescription without addressing the subtherapeutic INR level may not effectively prevent deep vein thrombosis. Administering Vitamin K is indicated for warfarin overdose leading to excessive anticoagulation, not for a subtherapeutic INR level that is below the target range.

4. What is the most appropriate nursing consideration for a patient who is prescribed verapamil and digoxin?

• A. Restrict intake of oral fluids and high-fiber foods
• B. Take an apical pulse for 30 seconds before administration
• C. Notify the healthcare provider of nausea, vomiting, and visual changes
• D. Hold the medications if the heart rate is greater than 110 bpm

Correct answer: C

Rationale: When a patient is prescribed verapamil and digoxin, it is crucial to monitor for signs of digoxin toxicity due to the potential interaction between these medications. Verapamil can elevate digoxin blood serum levels, increasing the risk of toxicity. Symptoms of digoxin toxicity include nausea, vomiting, and visual changes. Therefore, the most appropriate nursing consideration is to notify the healthcare provider of these symptoms. Restricting intake of oral fluids and high-fiber foods is not a specific consideration related to this medication combination. Before administering digoxin, it is essential to take an apical pulse for a full minute, not just 30 seconds, to ensure accuracy. Additionally, holding the medications if the heart rate exceeds 110 bpm is not a typical response to the combination of verapamil and digoxin, which can cause bradycardia rather than tachycardia.

5. The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child?

• A. 0.9% normal saline (NS)
• B.
• C. D5W
• D. Albumin

Correct answer: A

Rationale: Isotonic dehydration requires the administration of normal saline to restore fluid balance.

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