Nursing Elites

1. When developing a plan of care for a 6-year-old child diagnosed with acute glomerulonephritis, which intervention should the nurse prioritize?

• A. Encourage limited activity and provide safety measures.
• B. Catheterize the child to monitor intake and output strictly.
• C. Encourage the child to talk about feelings related to illness.
• D. Encourage classmates to visit and keep the child informed of school events.

Correct answer: A

Rationale: The priority intervention for a 6-year-old child diagnosed with acute glomerulonephritis should be to encourage limited activity and provide safety measures. In glomerulonephritis, children tend to restrict their activities voluntarily due to fatigue during the active phase of the disease. Catheterization for intake and output monitoring may predispose the child to infection and is not the primary intervention. Encouraging the child to talk about feelings related to the illness may not be developmentally appropriate for a 6-year-old; instead, children can express feelings through play. It is important to limit visitors to allow the child to rest and recover rather than encouraging classmates to visit and keep the child informed of school events.

2. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?

• A. Allergy to shellfish
• B. Apical pulse of 104
• C. Respiratory rate of 30
• D. Oxygen saturation of 90%

Correct answer: A

Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.

3. A client using an intraaural hearing aid experiences whistling after placement. What is the nurse's next action?

• A. Try to reposition the hearing aid
• B. Change the batteries
• C. Remove the device and have it cleaned
• D. Notify the physician that the hearing aid is not working

Correct answer: A

Rationale: An intraaural hearing aid, also known as an in-the-ear hearing aid, is placed in the ear canal. Whistling after placement indicates improper positioning of the device. The correct action for the nurse is to try repositioning the hearing aid to eliminate the whistling. Changing the batteries is not necessary for addressing whistling. Removing the device to clean it is not the immediate action needed for whistling. Notifying the physician is premature without attempting to reposition the hearing aid first.

4. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?

• A. Protect the neonate's eyes from the heat lamp
• B. Monitor the neonate's temperature
• C. Warm all medications and liquids before administration
• D. Avoid touching the neonate with cold hands

Correct answer: B

Rationale: When a newborn is placed in a warming isolette due to difficulty maintaining temperature, the priority action is to continuously monitor the neonate's temperature to prevent overheating. Using heat lamps is unsafe as their temperature cannot be regulated, potentially causing harm. Warming medications and fluids before administration is not necessary in this situation. While touching the neonate with cold hands may startle them, it does not pose a safety risk compared to monitoring and controlling the temperature.

5. Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?

• A. ''I just want to stab myself with this pen.''
• B. ''What's the point in life anyways?''
• C. ''My thoughts are racing because of the conspiracies against me.''
• D. ''I hear voices every day and sometimes see old friends that don't exist.''

Correct answer: C

Rationale: The correct answer is, ''My thoughts are racing because of the conspiracies against me.'' Schizoaffective disorder combines the symptoms of bipolar disorder (mania and depression) with those of schizophrenia (delusions and disturbed thought processes). Racing thoughts are a characteristic symptom of a manic episode, while beliefs in conspiracies indicate paranoia, which are common in schizoaffective disorder. Choices A, B, and D do not specifically align with the symptoms of schizoaffective disorder. Choice A suggests self-harm, which may be seen in various mental health conditions; choice B reflects existential questioning or depression; and choice D describes hallucinations, which are more characteristic of schizophrenia rather than schizoaffective disorder.

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