Nursing Elites

1. A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?

• A. The procedure typically takes 10 to 30 minutes.
• B. She may need to drink fluids before the test and may not void until the test has been completed.
• C. A probe coated with gel will be inserted into the vagina.
• D. She will be positioned on her back, with her head elevated and turned slightly to one side.

Correct answer: B

Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.

2. A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which action does the nurse take to help ensure the success of the interview?

• A. Ensuring that the room is private
• B. Having the client sit across from the nurse without a desk or table between them
• C. Maintaining a distance of 4 to 5 feet between the nurse and client
• D. Adjusting the room lighting to ensure it is comfortable and conducive for the client

Correct answer: A

Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained to avoid interruptions during the interview. This helps create a safe space for the client to share sensitive information. Having the client sit across from the nurse without a desk or table between them is also important to promote open communication and build rapport. Maintaining a distance of 4 to 5 feet from the client respects their personal space and helps prevent the client from feeling overwhelmed. While adjusting the room lighting is beneficial for creating a comfortable atmosphere, ensuring privacy is crucial for establishing trust and confidentiality. Therefore, ensuring that the room is private is crucial for the success of the interview, making choice A the correct answer. Choices B, C, and D are incorrect as they do not directly address the importance of privacy in creating a conducive environment for the interview.

3. The parents of a 2-year-old child ask the nurse how they can teach their child to stop taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child's behavior?

• A. "Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys."?
• B. "Your child is showing negativity. He doesn't want other children to have the toys he wants."?
• C. "Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys."?
• D. "Your child is engaging in domestic imitation. He is doing what he has seen other children do."?

Correct answer: A

Rationale: Two-year-old children are very egocentric, believing everything revolves around them. They think other children want them to have their toys, which explains why they may take toys from others. This behavior is typical for children at this age as they lack the ability to see things from another's perspective. Option B is incorrect because negativity in children this age is more related to refusal of requests rather than taking toys. Magical thinking, as described in option C, is usually seen in preschool-age children and involves unrealistic beliefs. Option D is incorrect as domestic imitation refers to imitating adult household tasks, not other children's behavior.

4. When a 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy, what should the nurse do first when interviewing the client?

• A. Assess the client's knowledge of available birth control methods.
• B. Inform the client that birth control methods can be discussed without the client's boyfriend present.
• C. Tell the client that for her age and lifestyle, birth control pills would be one of the methods of contraception.
• D. Give the client written material about various birth control methods and ask her to read them and to call if she has any questions.

Correct answer: A

Rationale: When a client seeks information about birth control, it is essential for the nurse to first assess the client's existing knowledge on the subject. This enables the nurse to provide tailored information that complements what the client already knows, facilitating better understanding and decision-making. Providing written material is a helpful educational tool but should not be the first intervention. Offering specific advice on birth control methods based on age and lifestyle limits the client's autonomy and decision-making process. Mentioning the client's boyfriend as a requirement for discussing birth control is inappropriate and nontherapeutic, as the client should be able to seek information independently.

5. An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?

• A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
• B. Checking the amniotic fluid for intrauterine infection
• C. Determination of fetal lung maturity
• D. Checking the fetal cells for chromosomal abnormalities

Correct answer: C

Rationale: The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.

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