Nursing Elites

1. In which part of the plan of care should a nurse record the item 'Encourage patient to attend one psychoeducational group daily'?

• A. Assessment
• B. Analysis
• C. Planning
• D. Implementation

Correct answer: D

Rationale: The correct answer is 'Implementation.' In the nursing process, implementation involves carrying out the planned interventions to meet the patient's goals. Encouraging the patient to attend a psychoeducational group daily is an intervention aimed at building social skills. Assessment (choice A) is the phase where data about the patient's condition is collected. Analysis (choice B) involves interpreting the gathered data. Planning (choice C) is where the nurse decides on the interventions to address the patient's needs. Therefore, in this scenario, recording the item 'Encourage patient to attend one psychoeducational group daily' would be part of the implementation phase.

2. The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?

• A. Irritability
• B. Slight edema at the injection site
• C. Local tenderness
• D. Temperature of 102.5?F

Correct answer: D

Rationale: A temperature of 102.5�F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.

3. A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

• A. Should be taken in the morning
• B. May increase the client's energy level
• C. Does not need to be stored in a dark container
• D. May increase the client's heart rate

Correct answer: A

Rationale: The correct answer is that levothyroxine (Synthroid) should be taken in the morning. Taking it in the morning can help prevent interference with the client's sleeping pattern, as one of the side effects of levothyroxine is insomnia. Choice B is incorrect because levothyroxine is actually used to treat hypothyroidism and can help increase energy levels. Choice C is incorrect as there is no specific requirement for levothyroxine to be stored in a dark container. Choice D is incorrect because levothyroxine is more likely to increase heart rate rather than decrease it.

4. A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:

• A. Expose the cast to air and turn the child frequently.
• B. Use a heat lamp to reduce the drying time.
• C. Handle the cast with the abductor bar.
• D. Turn the child as little as possible.

Correct answer: A

Rationale: After a hip spica cast is applied, it is important to facilitate drying by exposing the cast to air and turning the child frequently, approximately every 2 hours. This helps ensure even drying and prevents skin breakdown. Using a heat lamp can cause burns and should be avoided. Handling the cast with the abductor bar is not necessary for the drying process and may cause discomfort to the child. Turning the child as little as possible is not recommended as regular turning helps prevent complications like pressure ulcers and stiffness.

5. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that

• A. Circumcision is delayed so the foreskin can be used for the surgical repair
• B. This procedure is contraindicated because of the permanent defect
• C. There is no medical indication for performing a circumcision on any child
• D. The procedure should be performed as soon as the infant is stable

Correct answer: A

Rationale: Circumcision is delayed so the foreskin can be used for the surgical repair. Even if mild hypospadias is suspected, circumcision is not done to save the foreskin for surgical repair if needed. Choice B is incorrect because circumcision is not contraindicated due to a permanent defect; it is delayed for potential surgical needs. Choice C is incorrect as there are situations where a circumcision may be indicated for medical or cultural reasons. Choice D is incorrect because circumcision for hypospadias-related repair is not done immediately but rather delayed to preserve the foreskin for potential reconstructive surgery.

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