Nursing Elites

1. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

• A. Make a referral for grief counseling.
• B. Allow the woman to see her baby initially and respect her wishes for further visits.
• C. Provide opportunities for the woman to express her feelings.
• D. Inform the woman she has the right to change her mind about relinquishment.

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

2. A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?

• A. The fingers curl tightly, and the toes curl forward.
• B. The toes flare, and the big toe is dorsiflexed.
• C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
• D. The infant turns to the side that is touched.

Correct answer: B

Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.

3. During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?

• A. Cranial nerve X
• B. Cranial nerve V
• C. Cranial nerve IX
• D. Cranial nerve XII

Correct answer: D

Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.

4. How often should a 5-year-old child undergo a dental examination?

• A. Every 6 months
• B. Whenever a new primary tooth erupts
• C. Once a year
• D. Every 3 months

Correct answer: A

Rationale: For a 5-year-old child, dental examinations should be conducted every 6 months. This frequency allows for early detection of dental issues and promotes good oral health. Choices B, C, and D are incorrect because waiting for a new primary tooth to erupt, having an examination once a year, or every 3 months are not the recommended intervals for dental check-ups in this age group. It is essential to adhere to the standard guideline of every 6 months to ensure regular monitoring and preventive care for the child's dental health.

5. The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?

• A. Health promotion
• B. Secondary prevention
• C. Tertiary prevention
• D. Primary prevention

Correct answer: B

Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke. Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia. Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them. Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.

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