Nursing Elites

1. A nurse is covering a pediatric unit and is responsible for a 15-year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls."? The most appropriate course of action for the nurse is to respond by stating:

• A. "I will talk to the doctor about it."?
• B. "Has this been going on for a while?"?
• C. "How do you know this?"?
• D. "Teenagers often exhibit signs of sexual interest in females."?

Correct answer: D

Rationale: The most appropriate response for the nurse in this situation is to acknowledge that teenagers often exhibit signs of sexual interest in females. This response normalizes the mother's concern and provides reassurance that such behavior is typical during adolescence. Option A deflects the conversation to the doctor without addressing the mother's concern directly. Option B focuses on the duration rather than addressing the mother's statement. Option C may come off as defensive or dismissive, questioning the mother's observation. Therefore, the best response is to acknowledge the normalcy of teenage behavior regarding sexual interest.

2. What is the best position for a client immediately following a bilateral salpingooophorectomy?

• A. Fowler's
• B. Modified Sims
• C. Side lying
• D. Flat supine

Correct answer: C

Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (Choice A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (Choice B) is typically used for rectal examinations, not for post-surgical management. Flat supine (Choice D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.

3. The nurse is caring for a client admitted with Class III/IV Pulmonary Hypertension. The nurse explains to the client that Lanoxin is being administered to the client in order to:

• A. Manage peripheral edema
• B. Improve right ventricular function
• C. Increase pulmonary pressure
• D. Constrict the pulmonary vessels

Correct answer: B

Rationale: The correct answer is to improve right ventricular function. Lanoxin, also known as digoxin, is a cardiac glycoside that works by slowing the heart rate and increasing myocardial contractility, especially in the ventricles. This action helps improve the efficiency of the heart's pumping function, particularly the right ventricle in conditions like pulmonary hypertension. Choice A, managing peripheral edema, is not directly related to Lanoxin's mechanism of action. Choice C, increasing pulmonary pressure, is incorrect as Lanoxin is not used to increase pressure in the pulmonary circulation. Choice D, constricting the pulmonary vessels, is incorrect as Lanoxin does not cause vasoconstriction in the pulmonary vessels but rather acts on the heart's contractility.

4. A nurse is working in a pediatric clinic, and a 25-year-old mother comes in with a 4-week-old baby. The mother is stressed out about the loss of sleep, and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?

• A. Distraction of the infant with a red object
• B. Prone positioning techniques
• C. Tapping reflex techniques
• D. Neural warmth techniques

Correct answer: D

Rationale: Neural warmth techniques involve the caregiver providing a warm, soothing touch to the baby, which can help to lower the baby's agitation level and promote relaxation. This technique is beneficial for calming colicky babies. Choices A, B, and C are incorrect because distraction with a red object, prone positioning, and tapping reflex techniques are not effective methods for managing colic in infants. Red object distraction is not a proven technique for soothing colicky babies. Prone positioning is not recommended for infants due to the risk of sudden infant death syndrome (SIDS). Tapping reflex techniques are not recognized as effective interventions for colic.

5. The nurse is caring for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). In planning the client's care, the nurse should recognize that the child is likely to view this illness as?

• A. Punishment.
• B. Disturbance to body image.
• C. Rejection from parents.
• D. Change in routine with friends.

Correct answer: A

Rationale: The correct answer is A: Punishment. Preschool children often see illness as a form of punishment, especially when they are unable to understand the cause of their sickness. This perception is rooted in their limited cognitive abilities and understanding of health concepts. Choices B, C, and D are incorrect because preschool children are less likely to associate illness with disturbance to body image, rejection from parents, or changes in routine with friends. These options are not developmentally appropriate for how preschoolers typically interpret illness.

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