Nursing Elites

1. The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother?

• A. Infection always occurs when body piercing is done
• B. Hepatitis B is a concern with body piercing
• C. Body piercing is generally harmless as long as it is performed under sterile conditions
• D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)

Correct answer: C

Rationale: Generally, body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some complications that may occur include bleeding, infection, keloid formation, and the development of allergies to metal. It is essential to clean the area at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not typically associated with body piercing; however, they are a possibility with tattooing. Choice A is incorrect because infection does not always occur when body piercing is done. Choice B is not the best answer as hepatitis B is not commonly associated with body piercing. Choice D is incorrect because the risk of contracting HIV is not a significant concern with body piercing if performed under sterile conditions.

2. When assisting with data collection on language development in a toddler from a bilingual family, what characteristic would a nurse expect?

• A. Is more advanced than expected
• B. Is developing as expected
• C. Is slower than expected
• D. Will require assistance from a speech therapist

Correct answer: C

Rationale: When assessing language development in a toddler from a bilingual family, a nurse would expect the child's language development to be slower than expected. Various factors, such as physical maturity and reinforcement received, can influence the pace of language development. Children from bilingual families, twins, and non-firstborn children may exhibit slower language development. Therefore, it is common for the language development of a toddler from a bilingual family to be slower than expected. This characteristic does not necessarily imply a need for speech therapy. Choices A, B, and D are incorrect because, in this context, the language development of the child is more likely to be slower than expected rather than more advanced, developing as expected, or requiring speech therapy.

3. A healthcare provider is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the healthcare provider first place an activated tuning fork?

• A. On the client's teeth
• B. On the client's forehead
• C. On the client's mastoid bone
• D. On the midline of the client's skull

Correct answer: C

Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. Placing the tuning fork on the teeth (Choice A), forehead (Choice B), or the midline of the skull (Choice D) is not part of the Rinne test procedure. Therefore, the correct answer is to first place the activated tuning fork on the client's mastoid bone.

4. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetes Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.

5. A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?

• A. Initiate cardiopulmonary resuscitation
• B. Gently stimulate the infant by rubbing his back while administering oxygen
• C. Recheck the score in 5 minutes
• D. Provide no action except to support the infant's spontaneous efforts

Correct answer: B

Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.

Similar Questions