Nursing Elites

1. A nurse working in a pediatric clinic observes bruises on the body of a four-year-old boy. The parents report the boy fell while riding his bike. The bruises are located on his posterior chest wall and gluteal region. What should the nurse do?

• A. Suggest a script for counseling the family to the doctor on duty.
• B. Recommend a warm bath for the boy to decrease healing time.
• C. Notify the case manager in the clinic about possible child abuse concerns.
• D. Recommend ROM exercises to the patient's spine to decrease healing time.

Correct answer: C

Rationale: In this scenario, the nurse is observing bruises on a child's body that are located in areas not commonly associated with accidental injuries. Given the concerning nature of the bruising pattern and the inconsistent history provided by the parents, the nurse should suspect possible child abuse and take appropriate action by notifying the case manager in the clinic. The safety and well-being of the child should always be the top priority. Counseling for the family, warm baths, or recommending range of motion (ROM) exercises are not appropriate actions in this situation and may not address the underlying issue of potential child abuse.

2. A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?

• A. "I will call your physician to see if we can start some ginger."?
• B. "We don't use home remedies in this clinic."?
• C. "Herbs are not as effective as regular medicines."?
• D. "Just eat some dry crackers instead."?

Correct answer: A

Rationale: The correct response is to offer to consult with the physician regarding the use of ginger, showing cultural sensitivity. Ginger is known to help relieve nausea, especially in pregnancy. Choice A is the correct answer as it respects the client's preference for a home remedy and involves the physician in the decision-making process. Choice B dismisses the client's preference for a home remedy without exploring its potential benefits. Choice C makes a generalized statement discrediting the effectiveness of herbs, which is not evidence-based and disregards the client's beliefs. Choice D offers an alternative without addressing the client's specific request, failing to acknowledge the client's autonomy and cultural background.

3. Which of the following food selections would need to be removed from a tray for a client recovering from thyroidectomy?

• A. Fresh apple
• B. V8 juice
• C. Mustard greens
• D. Ice cream

Correct answer: A

Rationale: The correct answer is a fresh apple. After a thyroidectomy, it is important to avoid hard and crunchy foods like apples due to the proximity of the esophagus to the surgical site. Apples can be difficult to chew and swallow, posing a risk of injury or discomfort to the patient. V8 juice, mustard greens, and ice cream are softer options that would be more suitable for a client recovering from thyroidectomy.

4. What is the most effective strategy to assist a client in recognizing and using personal strength?

• A. Encouraging the client's self-identification of strengths.
• B. Promoting the client's active external thinking.
• C. Listening to the client and providing advice as needed.
• D. Assisting the client in maintaining an external locus of control.

Correct answer: A

Rationale: Encouraging the client to identify their own strengths is empowering and helps build self-awareness and self-confidence. This strategy promotes autonomy and self-efficacy, enabling the client to recognize and utilize their personal strengths effectively. Option B, promoting the client's active external thinking, is vague and not directly related to recognizing personal strengths. Option C, listening to the client and providing advice as needed, focuses more on the nurse's role rather than empowering the client to recognize their strengths independently. Option D, assisting the client in maintaining an external locus of control, goes against the goal of helping the client recognize and utilize their internal strengths.

5. Which statement best describes electrolytes in intracellular and extracellular fluid?

• A. There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid
• B. There is an equal concentration of sodium and potassium in extracellular fluid
• C. There is a greater concentration of potassium in extracellular fluid and sodium in intracellular fluid
• D. There is an equal concentration of sodium and potassium between intracellular and extracellular fluid

Correct answer: A

Rationale: Electrolytes are distributed unequally between intracellular and extracellular fluids. Sodium concentration is higher in extracellular fluid, while potassium concentration is higher in intracellular fluid. Therefore, the correct answer is 'There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.' Choices B, C, and D are incorrect because they do not accurately describe the typical distribution of sodium and potassium between intracellular and extracellular fluid.

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