Nursing Elites

1. An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?

• A. Loud music
• B. Use of power tools
• C. Occupational noise
• D. Exposure to cigarette smoke

Correct answer: D

Rationale: The correct answer is 'Exposure to cigarette smoke.' Otitis media (middle ear infection) is associated with various factors like colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include exposure to cigarette smoke, youth (as otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, family history of otitis media, recent upper respiratory infections, and allergies. Choices A, B, and C (Loud music, Use of power tools, and Occupational noise) are more likely to cause hearing loss rather than being direct risk factors for middle ear infections.

2. What is the most appropriate initial action for a newborn infant with low blood glucose?

• A. Ask the registered nurse to draw another blood sample in 2 hours and repeat the test
• B. Contact the healthcare provider
• C. Contact the registered nurse
• D. Document the results in the newborn's medical record

Correct answer: C

Rationale: The blood glucose level for a newborn infant should remain greater than 40 mg/dL to prevent permanent brain damage. When dealing with low blood glucose in a newborn, the most appropriate initial action is to contact the registered nurse. The nurse will obtain prescriptions regarding feeding the infant with low blood glucose and follow agency policies on feeding infants in such conditions. It is common practice to feed the infant if the glucose level is 40 mg/dL or less. Asking the registered nurse to draw another blood sample in 2 hours and repeating the test is not the most appropriate immediate action, as timely intervention is crucial in this situation. Contacting the healthcare provider may cause unnecessary delays since the registered nurse is usually the first point of contact for immediate actions in this scenario. Documenting the results in the newborn's medical record is essential, but it is not the initial step in managing low blood glucose in a newborn.

3. An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?

• A. emotional support to help the family cope with feelings of guilt about the infant's condition
• B. administration of MICRhoGam to the woman within 72 hours of delivery
• C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
• D. lab analysis of maternal Direct Coombs' test

Correct answer: A

Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs' test (Choice D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.

4. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

• A. Confirm the medical diagnosis.
• B. Make accurate nursing diagnoses.
• C. Identify any hereditary traits related to the epilepsy.
• D. Determine what the client believes has caused the epilepsy.

Correct answer: D

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

5. When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?

• A. dermabrasion
• B. rhinoplasty
• C. blepharoplasty
• D. rhytidectomy

Correct answer: D

Rationale: The correct answer is 'rhytidectomy.' Rhytidectomy, commonly known as a face-lift, is the procedure for removing excess skin from the face and neck. Dermabrasion involves spraying a chemical to freeze the skin lightly, followed by abrasion with sandpaper or a revolving wire brush, used for removing scars, severe acne, and tattoo pigment. Rhinoplasty is for improving the nose's appearance by reshaping the nasal skeleton and overlying skin. Blepharoplasty removes loose and protruding fat from the upper and lower eyelids. Therefore, when a client wants to address excess skin in the face and neck, rhytidectomy is the appropriate procedure.

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