Nursing Elites

1. A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?

• A. Provide information about the high-risk nature of her pregnancy.
• B. Gently remind the client that anti-rejection drugs can cause sterility.
• C. Explain the benefits of waiting for a five-year post-transplant period.
• D. Determine if the client is considering options for adopting a child.

Correct answer: A

Rationale: Post-liver transplant pregnancy is high-risk due to potential complications associated with immunosuppressive therapy and the transplanted organ's health. Providing information about the risks involved allows the client to make an informed decision regarding family planning.

2. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

3. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

• A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
• B. The chorea or movements are temporary and will eventually disappear.
• C. Permanent lifestyle changes are not needed to promote safety in the home.
• D. Consistent discipline is not directly related to controlling the movements.

Correct answer: B

Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course. Choices A, C, and D are incorrect because muscle tension, permanent lifestyle changes, and consistent discipline are not directly related to the resolution of chorea in rheumatic fever.

4. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?

• A. Graph the daily weight for the past week.
• B. Decrease IV flow rate.
• C. Assess bilateral lung sounds.
• D. Restrict intake of oral fluids.

Correct answer: C

Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.

5. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?

• A. Reduce cerebral edema and lower intracranial pressure
• B. Avert hypotension and septic shock
• C. Prevent cardiac arrhythmias and heart failure
• D. Promote kidney perfusion and normal blood pressure

Correct answer: A

Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.

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