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 nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

• A. The client receiving linear accelerator radiation therapy for lung cancer
• B. The client with a radium implant for cervical cancer
• C. The client who has just been administered soluble brachytherapy for thyroid cancer
• D. The client who returned from placement of iridium seeds for prostate cancer

Correct answer: A

Rationale: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is the correct choice because the radiation stays in the department, and the client is not radioactive. Choices B, C, and D involve clients who are radioactive or pose a risk due to radioactivity. The client with a radium implant for cervical cancer (choice B) is radioactive, the client who has just been administered soluble brachytherapy for thyroid cancer (choice C) is radioactive for approximately 72 hours, and the client who returned from placement of iridium seeds for prostate cancer (choice D) is also radioactive, especially right after the procedure. These options are not suitable for assignment to the pregnant nurse.

3. When helping a client gain insight into anxiety, the nurse should:

• A. help the client relate anxiety to specific triggers.
• B. ask the client to describe events that precede increased anxiety.
• C. encourage the client to practice relaxation techniques.
• D. address the client's resistive behavior.

Correct answer: B

Rationale: When assisting a client in gaining insight into anxiety, it is crucial to explore the events that lead to increased anxiety. By asking the client to describe these events, the nurse can help the client recognize patterns and triggers, leading to a better understanding of their anxiety. Option A is incorrect because it refers to triggers rather than exploring the events leading to anxiety. Option C is incorrect as it focuses on relaxation techniques rather than delving into the root causes of anxiety. Option D is inappropriate as addressing resistive behavior may not foster a supportive therapeutic environment for the client.

4. When planning care of a client who has been diagnosed with Amphetamine Abuse, the nurse should use the knowledge that:

• A. Amphetamines increase energy by increasing dopamine levels at neural synapses.
• B. Amphetamines have a low risk of tolerance or addiction.
• C. Amphetamines produce a 10-20-second rush followed by a 2-4-hour high.
• D. Addiction to barbiturates and amphetamines is rare because they have opposite effects.

Correct answer: A

Rationale: The correct answer is that amphetamines increase energy by increasing dopamine levels at neural synapses. Amphetamines cause the release of norepinephrine and dopamine from storage vesicles into the synapse, leading to increased stimulation. It is important to note that clear patterns of tolerance and withdrawal have not been described with amphetamines. Choice B is incorrect as prolonged or excessive use of amphetamines can lead to psychosis, indicating a potential for addiction. Choice C is incorrect as the duration of the effects of amphetamines is typically longer than 2-4 hours. Choice D is incorrect as addiction to amphetamines is not rare; in fact, drug cravings are common and can lead to relapse, indicating a significant risk of addiction.

5. Spirituality affects a client's life in all of the following areas except:

• A. nutritional intake.
• B. ability to handle stress.
• C. sexual expression.
• D. genetic makeup.

Correct answer: D

Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy. It can influence areas such as nutritional intake, the ability to handle stress, and sexual expression by providing comfort, guidance, and a sense of purpose. However, spirituality does not have any effect on genetic makeup, as genetics are determined by biological inheritance and not influenced by spiritual beliefs. Choices A, B, and C are directly influenced by an individual's spiritual beliefs and practices, impacting their overall well-being and behavior.

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