Nursing Elites

1. A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

• A. Low birth weight
• B. Advanced maternal age
• C. Single parenthood
• D. Premature birth

Correct answer: A

Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.

2. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

• A. The client's urine test is positive for glucose and acetone
• B. The client has 1+ pedal edema in both feet at the end of the day
• C. The client complains of an increase in vaginal discharge
• D. The client says she feels pressure against her diaphragm when the baby moves

Correct answer: A

Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.

3. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?

• A. Use a bed exit alarm to notify staff of attempts to leave the bed
• B. Raise all four side rails for safety
• C. Encourage frequent ambulation with assistance
• D. Use restraints to prevent the client from getting out of bed

Correct answer: A

Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.

4. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury for this client?

• A. Use a bed exit alarm system
• B. Raise all four side rails while the client is in bed
• C. Apply one soft wrist restraint
• D. Dim the lights in the client's room

Correct answer: A

Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.

5. A nurse is preparing to administer metoclopramide 10 mg IM. Available is metoclopramide 5 mg/mL. How many mL should the nurse administer?

• A. 1 mL
• B. 2 mL
• C. 3 mL
• D. 4 mL

Correct answer: B

Rationale: To administer 10 mg of metoclopramide, the nurse should administer 2 mL (10 mg / 5 mg per mL). Therefore, the correct answer is 2 mL. Choice A (1 mL) is incorrect because it would only deliver 5 mg of metoclopramide, which is half the required dose. Choice C (3 mL) and D (4 mL) are incorrect as they would provide more than the required dose of 10 mg.

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