Nursing Elites

1. The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother-infant bonding?

• A. Asking the mother to change her baby's diaper
• B. Assuring the mother that her baby is receiving excellent care
• C. Encouraging the mother to touch her baby whenever possible
• D. Keeping the mother informed about the care the nursing staff is providing her baby

Correct answer: C

Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother-infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother-infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby's diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.

2. After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. Which response would the nurse provide?

• A. ''This must be very difficult for you with this added pressure.''
• B. 'Having a child is a decision you should make without your parents' input.''
• C. 'You're lucky. It's nice that your parents are making such a generous offer.''
• D. ''Five years without a pregnancy is a long time. You were right to come to the fertility clinic.''

Correct answer: A

Rationale: The correct response acknowledges the emotional challenge the couple is facing due to the added pressure of the incentive from the husband's parents. By expressing empathy and understanding, the nurse encourages the couple to open up about their feelings and concerns. Choice B is not the best response as it dismisses the husband's situation and fails to address the emotional impact of the added pressure. Choice C focuses on the parents' offer rather than the couple's emotional state, which is not the primary concern in this situation. Choice D, mentioning the duration of infertility, may come across as insensitive and may hinder open communication by potentially making the couple feel judged or discouraged.

3. While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.

4. Which assessment data would be most important to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values?

• A. Dietary practices
• B. Concept of space
• C. Immigration status
• D. Role within the family

Correct answer: D

Rationale: The most important assessment data to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values is their role within the family. In traditional Asian cultures, the family holds significant importance and plays a central role in influencing an individual's well-being. Understanding the client's role within the family can provide crucial insights into their support system, stressors, and coping mechanisms. Dietary practices, concept of space, and immigration status, while potentially relevant, are not as vital in this context compared to understanding the dynamics and influence of the family structure on the individual's mental health.

5. Which activity would be most beneficial for a school-age client diagnosed with a chronic illness to enhance a sense of accomplishment?

• A. Wearing make-up
• B. Making up missed work
• C. Participating in sports activities
• D. Participating in creative activities

Correct answer: B

Rationale: Making up missed work is an essential activity that can help a school-age client diagnosed with a chronic illness feel a sense of accomplishment. By catching up on missed work, the child can regain a sense of control and productivity, which can be empowering during a challenging time. Wearing make-up is more related to personal grooming and self-expression, which may not directly contribute to a sense of accomplishment in this context. Participating in sports activities is beneficial for peer relationships and physical health but may not address the immediate need for accomplishment in the academic setting. Engaging in creative activities fosters cognitive development but may not directly address the sense of achievement associated with completing academic tasks.

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