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. A nurse is providing discharge instructions for a client who had back surgery. All of the following indicate that the client is ready for discharge EXCEPT:

• A. The client still has sutures at the incision site
• B. The client is able to take a shower
• C. The client must still use an ice pack at the wound site
• D. The client has a temperature of 100.8�F

Correct answer: D

Rationale: When determining if a client is ready for discharge after back surgery, it is essential to ensure that there are no signs of complications or emerging issues. A postoperative temperature of 100.8�F may indicate a developing infection, and the client should not be discharged until this is further evaluated by the physician. Choices A, B, and C are indicators that the client is progressing well and ready for discharge, as having sutures, being able to shower, and using an ice pack are typically expected postoperative activities without indicating a need for further hospitalization.

3. Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?

• A. Administer hypotonic solutions
• B. Keep the head of the bed elevated
• C. Increase the client's core body temperature to 99.9 degrees
• D. Administer corticosteroids as ordered

Correct answer: D

Rationale: Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.

4. A teacher brings a 5-year-old child to the school nurse because of a bruise under her eye. When asked about the bruise, the child responds, 'my daddy did it.' What is the nurse's initial action in this situation?

• A. Allow the child to return to class and monitor for future events that are suggestive of abuse
• B. Call the parent and request an explanation for the bruises
• C. Call the police and ask for a warrant for the parent's arrest
• D. Notify the school administrator

Correct answer: D

Rationale: In cases of suspected child abuse, the priority for the school nurse is to notify the school administrator immediately. The school administrator can then collaborate with the nurse to follow established protocols for reporting suspected abuse to the appropriate authorities. All suspicions or allegations of child abuse must be handled with sensitivity and in compliance with state laws and school policies. All other options, such as allowing the child to return to class without further action, directly contacting the parent, or involving the police without proper investigation, could potentially compromise the safety and well-being of the child and may not adhere to legal requirements for reporting suspected abuse.

5. Mrs. O is seen for follow-up after an episode of acute pancreatitis. Her physician orders a serum amylase level and the result is 200 U/L. Which of the following is a potential cause of this result?

• A. The client is pregnant
• B. The client has hypertension
• C. The client is in renal failure
• D. The client has pancreatitis

Correct answer: D

Rationale: An elevated serum amylase level after pancreatitis may indicate another attack of the condition. It is common to order serum amylase as part of routine follow-up after pancreatitis. Elevated levels can also be seen in related gastrointestinal conditions like cholecystitis or an intestinal blockage. Therefore, in this case, the most likely cause of the elevated serum amylase level is a recurrence or ongoing pancreatitis. The other options, including pregnancy, hypertension, and renal failure, are not typically associated with an elevated serum amylase level in the context of follow-up after acute pancreatitis.

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