Nursing Elites

1. A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs?

• A. Puffiness of the face
• B. Breast tenderness
• C. Morning sickness
• D. Urinary frequency

Correct answer: A

Rationale: During pregnancy, it is important to be aware of danger signs that warrant contacting the healthcare provider. Puffiness of the face, especially around the eyes, can indicate a serious condition like preeclampsia. Other danger signs include vaginal bleeding, rupture of membranes, severe abdominal pain, visual disturbances, persistent vomiting, and changes in fetal movements. Morning sickness, breast tenderness, and urinary frequency are common symptoms of pregnancy and are not typically concerning unless they become severe or persistent, and do not usually require immediate medical attention.

2. When performing the confrontation test to assess peripheral vision, what action should the nurse take?

• A. Asks the client to identify a small object brought into the visual field
• B. Has the client cover one eye while the nurse covers one eye and slowly advances a target midline between them
• C. Covers one eye, while the client covers the opposite eye, and brings a small object into the visual field
• D. Positions at eye level with the client, covers one eye, and has the client cover the opposite eye, then brings a small object into the visual field

Correct answer: D

Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits. Choices A, B, and C are incorrect. Choice A pertains to testing color vision, which is not part of the confrontation test. Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test. Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.

3. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

• A. Make a referral for grief counseling.
• B. Allow the woman to see her baby initially and respect her wishes for further visits.
• C. Provide opportunities for the woman to express her feelings.
• D. Inform the woman she has the right to change her mind about relinquishment.

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

4. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

• A. calcium
• B. magnesium
• C. potassium
• D. sodium chloride

Correct answer: D

Rationale: The correct answer is sodium chloride. Duodenal intestinal fluid is rich in potassium (K+), sodium (Na+), and bicarbonate. When suctioning is used to remove excess fluids due to ileus, it results in the loss of sodium chloride (NaCl) leading to decreased sodium (Na+) levels. Choices A, B, and C are incorrect because calcium, magnesium, and potassium are not typically lost in significant amounts through intestinal tube suction in the context of treating ileus.

5. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

• A. immobility
• B. altered growth and development
• C. hemarthrosis
• D. altered family processes

Correct answer: D

Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.

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