Nursing Elites

1. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

• A. inquire about the possibility of sexual abuse.
• B. ask about the types of foods the child is eating.
• C. request to see the type of bottle used for feedings.
• D. question the parent about objects the child plays with.

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

2. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?

• A. There is less chance of forgetting the medication if taken in the morning.
• B. There will be less fluid retention if taken in the morning.
• C. Prednisone is absorbed best with the breakfast meal.
• D. Morning administration mimics the body's natural secretion of corticosteroid.

Correct answer: D

Rationale: Taking corticosteroids in the morning mimics the body's natural release of cortisol, which follows a diurnal pattern with higher levels in the morning. This timing helps regulate the body's inflammatory response and minimizes potential side effects. Answer A is not the primary reason for morning dosing, as adherence concerns can be addressed through other means. Answer B is incorrect since fluid retention is not influenced by the timing of prednisone administration. Answer C is also incorrect as prednisone absorption is not significantly affected by whether it is taken with breakfast or not.

3. A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:

• A. naloxone (Narcan)
• B. labetalol (Normodyne)
• C. neostigmine (Prostigmin)
• D. thiothixene (Navane)

Correct answer: A

Rationale: The correct answer is naloxone (Narcan). Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression and somnolence. In this scenario, the client's extreme somnolence and respiratory depression suggest an opioid overdose, making naloxone the appropriate choice to counteract these effects. Labetalol (Normodyne) is a nonselective beta-blocker used to treat hypertension, not opioid overdose. Neostigmine (Prostigmin) is a cholinesterase inhibitor used to reverse neuromuscular blockade, not opioid-induced respiratory depression. Thiothixene (Navane) is an antipsychotic medication used to treat schizophrenia and is not indicated for opioid overdose.

4. When assessing a client in crisis, what should the nurse prioritize?

• A. Allowing the client to work through independent problem-solving.
• B. Completing an in-depth evaluation of stressors and responses to the situation.
• C. Focusing on immediate stress reduction.
• D. Recommending ongoing therapy.

Correct answer: C

Rationale: When a client is in crisis, the nurse's priority is to focus on immediate stress reduction. Crisis intervention aims to stabilize the client in the present moment by addressing the most pressing issues. Allowing the client to work through independent problem-solving (Choice A) may not be appropriate during a crisis as they might need immediate support. Completing an in-depth evaluation of stressors (Choice B) is important but not the immediate priority during a crisis. Recommending ongoing therapy (Choice D) may be considered later, but the immediate focus should be on reducing the client's stress and stabilizing the situation.

5. The client with diverticulosis is being assisted by the nurse in selecting appropriate foods. Which food should be avoided?

• A. Bran
• B. Fresh peaches
• C. Cucumber salad
• D. Yeast rolls

Correct answer: C

Rationale: The food that should be avoided for a client with diverticulosis is Cucumber salad. Foods with seeds should be avoided as they can aggravate diverticulosis by causing irritation and inflammation in the diverticula. Choices A, B, and D are allowed and even beneficial. Bran cereal and fruit like fresh peaches can help prevent constipation, which is beneficial for individuals with diverticulosis. Yeast rolls are also acceptable unless the client has specific dietary restrictions related to yeast or gluten.

Similar Questions