Nursing Elites

1. As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?

• A. builds towers with several blocks
• B. tries to color within the lines
• C. says 'Mine!' when playing with toys
• D. tries to jump rope

Correct answer: C

Rationale: The correct answer is C: 'says 'Mine!' when playing with toys.' At the age of 2, children are in the stage of parallel play and are possessive of their belongings, hence saying 'Mine!' is an age-appropriate behavior. Building towers with blocks (choice A) involves more advanced motor skills and cognitive abilities, which are beyond what most 2-year-olds can do. Trying to color within the lines (choice B) requires fine motor skills that are typically not developed at age 2. Jumping rope (choice D) involves coordination and balance that are beyond the capabilities of a 2-year-old child.

2. The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?

• A. Ask the healthcare provider about referring the client to a neurological specialist.
• B. Obtain a prescription for a muscle relaxant.
• C. Notify the healthcare provider immediately.
• D. Document the findings.

Correct answer: D

Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.

3. A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?

• A. Keeping up with schoolwork
• B. Body image
• C. Obtaining adequate rest and sleep
• D. Obtaining adequate nutrition

Correct answer: B

Rationale: The correct answer is 'Body image.' Adolescents, especially teenage girls, are often preoccupied with their appearance and body image. When facing a situation like being in skeletal traction, which can affect their physical appearance, body image becomes a primary concern. Concerns about body image can significantly impact their self-esteem and emotional well-being. Choice A, 'Keeping up with schoolwork,' is important but typically not the primary concern in this context. Choices C and D, 'Obtaining adequate rest and sleep' and 'Obtaining adequate nutrition,' are crucial for overall health but are secondary to the significant impact that body image concerns can have on a teenage girl in this situation.

4. A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the healthcare provider expect to administer in addition to the scheduled vaccines?

• A. pneumococcal vaccine
• B. hepatitis A vaccine
• C. Lyme disease vaccine
• D. typhoid vaccine

Correct answer: A

Rationale: The correct answer is the pneumococcal vaccine. Children with HIV are at increased risk of pneumococcal infections, so the pneumococcal vaccine is recommended as a supplemental vaccine for them. The hepatitis A vaccine is not routinely given to HIV-positive children unless they have other risk factors for hepatitis A. Lyme disease vaccine is for individuals at risk for Lyme disease, not routinely recommended for a 2-year-old. Typhoid vaccine is typically given to individuals traveling to endemic areas or working in settings with potential exposure to Salmonella typhi, not a routine vaccine for a 2-year-old with HIV.

5. Which of the following are included in the Rights of Medication Administration? Select all that apply.

• A. Right dose, right time, right explanation, right client, right route
• B. Right dose, right time, right client, right route
• C. Right dose, right time, right client
• D. Right time, right explanation, right client

Correct answer: B

Rationale: The Rights of Medication Administration include the right client, right drug, right dose, right route, and right time. An additional right that is sometimes included is the right documentation. The correct answer includes the essential rights that must be ensured during medication administration. Choice A is incorrect as 'right explanation' is not part of the traditional Rights of Medication Administration. Choice B is incorrect as 'right explanation' is not included, and choice C is missing the right route. Choice D is incorrect as it lacks the right dose and right route.

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