Nursing Elites

1. The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?

• A. Early diagnosis and treatment provide the only means for a cure of ASD.
• B. Early diagnosis and treatment gives your child the best chance of becoming a fully functioning adult.
• C. Early diagnosis and treatment provides the best way to ensure that your child can be admitted to an assisted living facility as an adult.
• D. Early diagnosis and treatment prevent your child from developing any other mental condition.

Correct answer: B

Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills. Choice A is incorrect as there is currently no cure for ASD. Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility. Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.

2. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

• A. Altered tissue perfusion
• B. Risk for fluid volume deficit
• C. High risk for hemorrhage
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.

3. While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?

• A. Abdominal respirations
• B. Inspiratory grunt
• C. Nasal flaring
• D. Cyanosis

Correct answer: A

Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.

4. All of the following are essential components of supervision EXCEPT:

• A. All tasks to be delegated or supervised are within the nurse's scope of practice
• B. The necessary tasks require repeated assessments
• C. The nurse has adequate time to develop staff assignments
• D. Policies have been developed that govern nursing practice

Correct answer: B

Rationale: Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.

5. You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:

• A. PT referral for development of a planned exercise program
• B. Avoidance of prolonged sun exposure
• C. Hot baths to promote muscle relaxation
• D. Instructions to evaluate the home environment to ensure safety

Correct answer: C

Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.

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