Nursing Elites

1. A nurse in a day-care setting is planning play activities for 2- and 3-year-old children. Which toys are most appropriate for these activities?

• A. Finger paints and card games
• B. Blocks and push-pull toys
• C. Videos and cutting-and-pasting toys
• D. Simple board games and puzzles

Correct answer: B

Rationale: The most appropriate toys for 2- and 3-year-old children in a day-care setting are blocks and push-pull toys. Toddlers enjoy objects of different textures like clay, sand, finger paints, and bubbles, as well as push-pull toys, large balls, and sand and water play. They also like activities such as blocks, painting, coloring with large crayons, large puzzles, and playing with trucks or dolls. Finger paints and card games may be more suitable for older children. Videos and cutting-and-pasting toys are generally more appropriate for preschoolers. Blocks and push-pull toys are beneficial for young children as they help in developing fine motor skills, hand-eye coordination, spatial awareness, and creativity. These toys also encourage imaginative play and problem-solving, making them ideal choices for toddlers.

2. A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?

• A. Immunizations may be started at any age.
• B. The recommended immunization schedule should be followed.
• C. If a primary series of immunizations is interrupted, it can be continued.
• D. Delaying the start of vaccines does not increase the risk of reaction.

Correct answer: A

Rationale: The correct answer is 'Immunizations may be started at any age.' While there is a recommended immunization schedule, immunizations can be initiated at any age. It is essential to emphasize the flexibility in starting immunizations. The statement 'The recommended immunization schedule should be followed' is too rigid; while recommended, there is flexibility in initiation. Choice C is correct as an interrupted series can be continued without restarting. The statement 'Delaying the start of vaccines does not increase the risk of reaction' is correct. Delaying does not increase the risk of reaction; in fact, it is important to start immunizations to protect the child and the community.

3. A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which topic does the nurse ask the client about first?

• A. Her sexual history
• B. Her menstrual history
• C. Her obstetrical history
• D. The presence of vaginal drainage

Correct answer: B

Rationale: The nurse should begin by asking the client about her menstrual history as it is usually nonthreatening. This information can provide insights into the client's reproductive health and any irregularities. Menstrual history is a common starting point for gynecological assessments and can help in understanding the client's overall health status. Asking about sexual history may be more sensitive and personal, not always appropriate to start with. Obstetrical history pertains to pregnancies and may not be relevant if the client has not been pregnant. Inquiring about the presence of vaginal drainage is important but is usually addressed after gathering more general information about the client's health.

4. An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?

• A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
• B. Checking the amniotic fluid for intrauterine infection
• C. Determination of fetal lung maturity
• D. Checking the fetal cells for chromosomal abnormalities

Correct answer: C

Rationale: The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.

5. 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.

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