Nursing Elites

1. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

• A. Risk for Self-Harm
• B. Body Image Disturbance
• C. Ineffective Role Performance
• D. Powerlessness

Correct answer: B

Rationale: The correct answer is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and completeness related to infertility, indicating a disturbance in body image perception. 'Risk for Self-Harm' is not the best choice as there is no indication of immediate self-harm. 'Ineffective Role Performance' is less appropriate since the statement does not directly relate to a disruption in the parent's role. 'Powerlessness' could be considered if the client expressed feelings of powerlessness specifically related to the infertility issue.

2. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

3. A nurse, assigned to care for a hospitalized child who is 8 years old, assists with planning care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child?

• A. Developing a sense of control over self and body functions
• B. Mastering useful skills and tools
• C. Gaining independence from parents
• D. Developing a sense of trust in the world

Correct answer: B

Rationale: According to Erikson's theory of psychosocial development, the primary task for an 8-year-old child aligns with the stage of industry versus inferiority. This stage focuses on mastering useful skills and tools of the culture, emphasizing competence in various areas. Option A, 'Developing a sense of control over self and body functions,' is more characteristic of the toddler stage, emphasizing autonomy and self-regulation. Option C, 'Gaining independence from parents,' is more relevant to the adolescent stage, where identity development and autonomy become crucial. Option D, 'Developing a sense of trust in the world,' pertains to the infant stage, highlighting the importance of forming secure attachments. Therefore, the correct answer is B as it directly corresponds to the developmental tasks associated with an 8-year-old child according to Erikson's theory.

4. The client has an order for 0.45 mg of Diltiazem. The medication vial has a concentration of 3 mg/mL. How many mL of the drug should be administered?

• A. 0.15 mL
• B. 6.6 mL
• C. 1.5 mL
• D. 0.65 Ml

Correct answer: A

Rationale: To calculate the amount of drug to be administered, divide the ordered dose by the concentration of the medication in the vial. In this case, 0.45 mg � 3 mg/mL = 0.15 mL. Therefore, the correct answer is 0.15 mL. Choice B (6.6 mL) is incorrect as it does not result from the correct calculation. Choice C (1.5 mL) is incorrect as it is not the result of dividing the ordered dose by the concentration. Choice D (0.65 mL) is incorrect as it is not the accurate calculation based on the provided information.

5. A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm, and the color is pink. What action should the nurse perform next to prevent ischemia?

• A. Notify the physician immediately
• B. Obtain a Doppler device to check for pulses, and notify the physician if they are still absent
• C. Wait 30 minutes and recheck the pulses
• D. Document the finding

Correct answer: B

Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial pulses can be difficult to assess and might need to be verified with a Doppler device. Since the client just had surgery with a risk of arterial insufficiency, close monitoring is crucial. If pulses are not palpable, it indicates an emergent situation requiring immediate physician notification. Waiting 30 minutes before reassessment could lead to foot ischemia. While documenting findings is essential, it should follow pulse confirmation or necessary interventions to ensure the client's foot viability.

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