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. A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?

• A. Allow the toddler to play with other children in the nursing unit playroom.
• B. Spend as much time as possible with the toddler.
• C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room.
• D. Keep hospital routines as similar as possible to those at home.

Correct answer: D

Rationale: The best action for the nurse to take to help a hospitalized toddler maintain a sense of control and security and ease feelings of helplessness and fear is to keep hospital routines as similar as possible to those at home. By incorporating the toddler's usual rituals and routines from home into nursing care activities, the nurse can reduce the stress of hospitalization. This approach gives the toddler a sense of familiarity, control, and security, which can alleviate feelings of helplessness and fear. Allowing the toddler to play with other children in the nursing unit playroom and selecting toys are beneficial activities, but maintaining hospital routines similar to those at home is the most effective way to support the toddler's emotional well-being during hospitalization.

3. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

• A. The client has a history of Type II diabetes.
• B. The client is on a continuous tube-feeding regimen.
• C. The client is on fluid restriction.
• D. The pharmacy has provided phenytoin in tablet form.

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

4. 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.

5. A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider?

• A. "If I go from a very bright room to a very dark room, I have some trouble adjusting."
• B. "I have to hold my newspaper farther and farther away from me when I read."
• C. "I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me."
• D. "It looks like I have a blank spot in the middle of what I'm trying to see."

Correct answer: D

Rationale: The correct answer is "It looks like I have a blank spot in the middle of what I'm trying to see." Seeing blank spots in the middle of an object is a sign of central vision loss, which is a symptom of macular degeneration. Macular degeneration is a serious condition that requires immediate discussion with a healthcare provider to prevent further vision loss. Choice A, mentioning difficulty adjusting between bright and dark rooms, is a common issue related to changes in lighting and not a cause for immediate concern. Choice B, having to hold objects farther away when reading, is indicative of presbyopia, a normal age-related change in vision. Choice C, experiencing slight changes in color perception, is also a common age-related change and not an urgent issue that necessitates immediate discussion with a healthcare provider.

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