Nursing Elites

1. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

• A. Confirm the medical diagnosis.
• B. Make accurate nursing diagnoses.
• C. Identify any hereditary traits related to the epilepsy.
• D. Determine what the client believes has caused the epilepsy.

Correct answer: D

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

2. The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should provide which response to the parents?

• A. That this is normal behavior for an adolescent
• B. That their daughter's behavior may be a part of adolescent development
• C. That this behavior could be a phase as the adolescent explores identity
• D. To restrict any social privileges until the behavior stops

Correct answer: A

Rationale: During adolescence, identity formation is a significant developmental task. Adolescents may appear self-centered, lazy, or irresponsible as they focus on themselves and explore their identity. Erikson describes this phase as identity formation versus role confusion. It is common for frustrated parents to perceive teenagers this way. The adolescent needs time to introspect and develop a sense of self. Suggesting that the behavior requires a child psychologist is premature and not supported by normal adolescent development. Blaming the behavior on parental spoiling is also inaccurate and unhelpful. Restricting social privileges can lead to resentment and rebellion, rather than addressing the root of the behavior.

3. A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?

• A. Uses a cotton-tipped swab to carefully clean inside the infant's nose
• B. Uncovers only the body part being washed
• C. Washes the diaper area first
• D. Washes the infant's chest first

Correct answer: B

Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.

4. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?

• A. Administering an intravenous (IV) opioid analgesic
• B. Assisting the woman in taking a warm sitz bath
• C. Applying an ice pack to the perineum
• D. Contacting the registered nurse

Correct answer: C

Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.

5. Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?

• A. intrauterine device (IUD)
• B. Norplant
• C. oral contraceptives
• D. vaginal sponge

Correct answer: D

Rationale: The correct answer is the vaginal sponge. The vaginal sponge, when used with foam or jelly contraception, acts as a barrier method that can reduce the transmission of HIV and other STDs, in addition to preventing pregnancy. In contrast, IUDs, Norplant, and oral contraceptives are effective in preventing pregnancy but do not provide protection against the transmission of HIV and STDs. IUDs prevent pregnancy by affecting sperm movement and survival, Norplant releases hormones to prevent ovulation, and oral contraceptives work by inhibiting ovulation. However, these methods do not create a physical barrier against HIV and STD transmission. It is important to counsel clients using methods like IUDs, Norplant, and oral contraceptives to also use chemical or barrier contraceptives to lower the risk of HIV or STD transmission.

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