Nursing Elites

1. While assisting a female client to the toilet, the client begins to have a seizure, and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

• A. Document details of the seizure activity.
• B. Observe for lacerations on the tongue.
• C. Observe for prolonged periods of apnea.
• D. Evaluate for evidence of incontinence.

Correct answer: A

Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.

2. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?

• A. Right side-lying
• B. Left side-lying
• C. Prone
• D. Supine

Correct answer: D

Rationale: The correct answer is D, supine. The American Academy of Pediatrics recommends placing infants on their back, or supine, to sleep as it has been shown to reduce the risk of SIDS. Choices A, B, and C are incorrect because placing infants on their right side, left side, or prone (on their stomach) respectively are not recommended sleeping positions due to the increased risk of SIDS associated with those positions.

3. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?

• A. Hypotension
• B. Tachycardia
• C. Severe headache
• D. Flushed skin below the level of injury

Correct answer: C

Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.

4. A client is receiving intravenous potassium chloride for hypokalemia. Which action should the nurse take to prevent complications during the infusion?

• A. Administer the infusion rapidly
• B. Monitor the infusion site for signs of infiltration
• C. Use a syringe pump for the infusion
• D. Flush the IV line with normal saline before starting the infusion

Correct answer: B

Rationale: The correct action to prevent complications during the infusion of potassium chloride is to monitor the infusion site for signs of infiltration. Rapid administration can lead to adverse effects, including cardiac arrhythmias. Using a syringe pump is not typically necessary for this infusion. Flushing the IV line with normal saline is a good practice but not directly related to preventing complications specifically during the infusion of potassium chloride.

5. The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?

• A. The causes of major depression are unknown.
• B. Major affective disorders in parents increase depression in children.
• C. Boys are more likely than girls to be depressed.
• D. The prevalence rate is higher in prepubescent children.

Correct answer: B

Rationale: The correct answer is B because while the exact causes of depression in children are not fully understood, research indicates that children are more likely to experience depression if their parents have a major affective disorder. Choice A is incorrect because it suggests that the causes of major depression are entirely unknown, which is not accurate. Choice C is incorrect as there is no conclusive evidence that boys are more likely than girls to be depressed. Choice D is incorrect as the prevalence rate of depression is not necessarily higher in prepubescent children specifically.

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