Nursing Elites

1. The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?

• A. Peabody Picture Vocabulary Test
• B. The Modified Checklist for Autism in Toddlers (M-CHAT)
• C. Wechsler Preschool and Primary Scale of Intelligence
• D. Denver Developmental Screening Test

Correct answer: B

Rationale: The Modified Checklist for Autism in Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (Choice A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (Choice C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (Choice D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.

2. A client with a history of alcohol abuse presents with confusion and unsteady gait. The nurse suspects Wernicke's encephalopathy. Which treatment should the nurse anticipate?

• A. Thiamine supplementation
• B. Folic acid replacement
• C. Intravenous glucose
• D. Magnesium sulfate administration

Correct answer: A

Rationale: Wernicke's encephalopathy is a neurological condition commonly caused by a deficiency in thiamine, often seen in clients with chronic alcohol abuse. Thiamine supplementation is the primary treatment to prevent further neurological damage. Folic acid replacement (choice B) is not the correct treatment for Wernicke's encephalopathy. Intravenous glucose (choice C) may be necessary in some cases of Wernicke's encephalopathy, but thiamine supplementation takes precedence. Magnesium sulfate administration (choice D) is not indicated as the primary treatment for Wernicke's encephalopathy.

3. An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?

• A. Have the UAP recheck the pulse and report back.
• B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
• C. Call the healthcare provider for further instructions.
• D. Immediately call the healthcare provider and prepare for transfer to critical care.

Correct answer: B

Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client’s cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.

4. A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?

• A. Monitor the site for further complications.
• B. Promptly remove the catheter from the radial artery.
• C. Elevate the client’s arm above the heart.
• D. Notify the healthcare provider and prepare for surgery.

Correct answer: B

Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.

5. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A. Decreased urinary output
• B. Jugular vein distention
• C. Pleural effusion
• D. Bibasilar crackles

Correct answer: B

Rationale: Correct! In right-sided congestive heart failure, jugular vein distention is a common finding due to the backup of blood in the systemic circulation. This results in increased venous pressure, leading to jugular vein distention. Choices A, C, and D are incorrect because decreased urinary output, pleural effusion, and bibasilar crackles are more commonly associated with other conditions such as kidney dysfunction, lung issues, and pulmonary edema.

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