Nursing Elites

1. The parents of a 2-year-old child ask the nurse how they can teach their child to stop taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child's behavior?

• A. "Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys."?
• B. "Your child is showing negativity. He doesn't want other children to have the toys he wants."?
• C. "Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys."?
• D. "Your child is engaging in domestic imitation. He is doing what he has seen other children do."?

Correct answer: A

Rationale: Two-year-old children are very egocentric, believing everything revolves around them. They think other children want them to have their toys, which explains why they may take toys from others. This behavior is typical for children at this age as they lack the ability to see things from another's perspective. Option B is incorrect because negativity in children this age is more related to refusal of requests rather than taking toys. Magical thinking, as described in option C, is usually seen in preschool-age children and involves unrealistic beliefs. Option D is incorrect as domestic imitation refers to imitating adult household tasks, not other children's behavior.

2. A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?

• A. Emergency
• B. Follow-up
• C. Complete (total)
• D. Problem-centered

Correct answer: B

Rationale: The correct answer is 'Follow-up.' A follow-up database is used to assess the status of an identified problem at regular intervals. An emergency database is for urgent data collection during life-saving measures. A complete database involves a full health history and physical examination. A problem-centered (episodic) database focuses on a limited or short-term issue, typically centered around one problem or body system.

3. The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should provide which response to the parents?

• A. That this is normal behavior for an adolescent
• B. That their daughter's behavior may be a part of adolescent development
• C. That this behavior could be a phase as the adolescent explores identity
• D. To restrict any social privileges until the behavior stops

Correct answer: A

Rationale: During adolescence, identity formation is a significant developmental task. Adolescents may appear self-centered, lazy, or irresponsible as they focus on themselves and explore their identity. Erikson describes this phase as identity formation versus role confusion. It is common for frustrated parents to perceive teenagers this way. The adolescent needs time to introspect and develop a sense of self. Suggesting that the behavior requires a child psychologist is premature and not supported by normal adolescent development. Blaming the behavior on parental spoiling is also inaccurate and unhelpful. Restricting social privileges can lead to resentment and rebellion, rather than addressing the root of the behavior.

4. Which of the following is not a nursing responsibility when preparing the client for central line insertion?

• A. advancing the guidewire
• B. explaining the procedure to the client
• C. maintaining sterile technique
• D. ensuring necessary consents are signed

Correct answer: A

Rationale: When preparing a client for central line insertion, nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. Advancing the guidewire is typically performed by the practitioner inserting the central line, not the nurse. It requires specialized training and expertise beyond the scope of nursing practice. Therefore, the correct answer is advancing the guidewire. Option A is the correct answer because it delineates an activity that is not within the usual scope of nursing practice during central line insertion preparation. Options B, C, and D are incorrect as they reflect essential nursing responsibilities in this context.

5. When removing hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward.
• B. Grasp the lens with a gentle pinching motion.
• C. Don sterile gloves before attempting the procedure.
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.

Correct answer: D

Rationale: When removing hard contact lenses, it is crucial to ensure that the lens is correctly positioned on the cornea before removal. Directly grasping the lens can potentially scratch the cornea, so it is essential to gently manipulate the lids to release the lens safely. Gently irrigating the eye is unnecessary and could be harmful, especially without the client's cooperation. Wearing sterile gloves is also unnecessary for this specific procedure. Therefore, the correct approach is to ensure the proper positioning of the lens and then gently manipulate the lids to release it. Options A and C are incorrect because irrigating the eye and wearing sterile gloves are not necessary for contact lens removal. Option B is incorrect as directly grasping the lens can be harmful to the cornea.

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