Nursing Elites

1. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

• A. Pain related to periosteal injury
• B. Impaired mobility related to bleeding
• C. Parental anxiety related to knowledge deficit
• D. Injury related to intracranial hemorrhage

Correct answer: C

Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.

2. Which of the following statements is correct regarding community health nursing?

• A. Evaluation of the health status of individuals and families should be done in consultation with them.
• B. The public health nurse (PHN) who works with communication for 6 can solely determine the needs of the community.
• C. Provision of PHN care is not in any way affected by policies of the agency where the nurse works.
• D. Professional growth and development of the PHN is the responsibility of the Department of Health (DOH).

Correct answer: A

Rationale: The correct statement is that evaluation of the health status of individuals and families should be done in consultation with them. This approach ensures that the assessment is accurate and takes into account the perspectives and concerns of the individuals and families involved. Choice B is incorrect because determining the needs of the community should involve input from various stakeholders, not solely the PHN. Choice C is incorrect as the provision of PHN care can be influenced by the policies of the agency or organization where the nurse works. Choice D is also incorrect as while the DOH may play a role in setting standards, the professional growth and development of a PHN is typically a personal and professional responsibility.

3. The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by

• A. Inserting a fenestrated catheter with a whistle tip without suction
• B. Completing the suction pass in 30 seconds with a pressure of 150 mm Hg
• C. Hyperoxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass
• D. Minimizing the suction pass to 60 seconds while slowly rotating the lubricated catheter

Correct answer: C

Rationale: Hyperoxygenating the client before and after suctioning helps prevent hypoxia by ensuring adequate oxygen levels during the procedure, which briefly interrupts the client's normal breathing pattern. Choice A is incorrect because inserting a fenestrated catheter with a whistle tip without suction would not prevent hypoxia. Choice B is incorrect as completing the suction pass in 30 seconds with a pressure of 150 mm Hg may lead to hypoxia. Choice D is incorrect as minimizing the suction pass to 60 seconds may not provide enough time for effective suctioning and could lead to hypoxia.

4. When assessing a child with acute respiratory infection, what nursing intervention(s) would be appropriate?

• A. Provide safe remedies to relieve the child's sore throat and cough
• B. All of these interventions
• C. Advise the mother to monitor for signs of pneumonia
• D. Ensure proper nutrition to prevent weight loss

Correct answer: B

Rationale: In the management of acute respiratory infection in a child, it is essential to address various aspects of care. Providing safe remedies to relieve symptoms like sore throat and cough (Choice A) helps in managing discomfort. Advising the mother to monitor for signs of pneumonia (Choice C) is crucial for early detection and intervention if complications arise. Ensuring proper nutrition (Choice D) is important for the child's overall health and immune function during illness. Therefore, all the listed interventions are appropriate in managing acute respiratory infection, making Choice B the correct answer. Choices A, C, and D are incorrect on their own as they address only specific aspects of care and not the comprehensive management of acute respiratory infection.

5. During a large community disaster, a man states that the blast threw him out of a second-story window. Which action should the nurse implement first?

• A. Logroll the client to his side and assess for back injuries
• B. Perform a complete neurological assessment
• C. Open the client's airway immediately
• D. Place the nurse's hands around the client's neck to stabilize

Correct answer: D

Rationale: In this situation, the nurse should first stabilize the client's neck to prevent potential spinal cord injuries. Logrolling the client or performing other assessments should only be done after ensuring spinal stabilization. Opening the airway immediately is important in cases of airway obstruction, but stabilizing the neck takes priority in this scenario. Performing a complete neurological assessment may delay immediate stabilization, which is crucial in suspected spinal injuries.

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