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. A mother has just given birth to a baby who died soon after. The mother has been crying and states, "I can't believe this has happened to me. I did everything right during this pregnancy."? How should the nurse respond to this mother?

• A. Tell her she did nothing wrong; it was God's will.
• B. Tell her she can have another baby.
• C. Tell her that her behavior is not going to solve anything.
• D. Tell her nothing and let her mourn this loss in the manner she chooses.

Correct answer: D

Rationale: Perinatal loss is a significant tragedy for parents, and it is crucial to provide sensitive and compassionate care. When a mother expresses her disbelief and feelings of doing everything right during the pregnancy, it is important for the nurse to acknowledge her pain and allow her to grieve in her way. Telling her that she did nothing wrong and it was God's will (Choice A) may not be comforting and can come across as dismissive of her feelings. Suggesting she can have another baby (Choice B) is insensitive and overlooks the grief she is experiencing for the current loss. Telling her that her behavior is not going to solve anything (Choice C) is invalidating her emotions and not supportive in this situation. Therefore, the best approach is to support her in her mourning process by respecting her feelings and allowing her to express her grief as she sees fit.

3. The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:

• A. reactive.
• B. maturational.
• C. situational.
• D. adventitious.

Correct answer: C

Rationale: The mother is experiencing a situational crisis as the unexpected birth of a child with a cleft lip and palate has placed her in a challenging situation she did not anticipate. This type of crisis is triggered by specific events and circumstances. Choice A, reactive, implies responding to a stressor after it has occurred, which is not the case here. Choice B, maturational, refers to stress related to developmental stages, not to external events like the child's condition. Choice D, adventitious, involves crises resulting from events outside one's control, such as natural disasters, which do not apply in this scenario.

4. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

• A. Decreased appetite
• B. A low-grade fever
• C. Chest congestion
• D. Constant swallowing

Correct answer: D

Rationale: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade fever; thus, answers A and B are incorrect. Chest congestion, as mentioned in answer C, is not typical of tonsillectomy complications, making it an incorrect choice.

5. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:

• A. Offering hard candy
• B. Administering analgesic medications
• C. Splinting swollen joints
• D. Providing saliva substitute

Correct answer: D

Rationale: Xerostomia is dry mouth, a common side effect in cancer patients. Providing a saliva substitute helps alleviate the discomfort associated with dry mouth by moistening the oral mucosa. Offering hard candy, as mentioned in choice A, can worsen xerostomia by increasing sugar content and potentially causing irritation. Administering analgesic medications, as in choice B, is not directly related to treating dry mouth. Splinting swollen joints, as in choice C, is irrelevant to xerostomia, which primarily affects the oral cavity.

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