Nursing Elites

1. A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: B

Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.

2. Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?

• A. Rectus femoris muscle
• B. Deltoid muscle
• C. Gluteal muscle
• D. Vastus lateralis muscle

Correct answer: D

Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.

3. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

• A. "I should not put alcohol on my baby's cord 3-4 times a day."?
• B. "I should not put the baby's diaper on so that it covers the cord."?
• C. "I should call the physician if the cord becomes dark."?
• D. "I should wash my hands before and after I take care of the cord."?

Correct answer: B

Rationale: Parents should be taught not to cover the cord with a diaper to allow for air exposure and drying, preventing infection. The statement 'I should put alcohol on my baby's cord 3-4 times a day' indicates a need for further teaching as current recommendations do not include using alcohol on the cord, which can interfere with natural healing. While it is normal for the cord to turn dark as it dries, so the statement 'I should call the physician if the cord becomes dark' is accurate, it is not the best answer for this question. Washing hands before and after caring for the cord is important to prevent the transfer of pathogens, so this statement does not require further teaching.

4. 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.

5. When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?

• A. Robert Peck
• B. Erik Erikson
• C. Sigmund Freud
• D. Jean Piaget

Correct answer: B

Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.

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