Nursing Elites

1. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child?

• A. Excessive growth
• B. Cognitive impairment
• C. Damage to the nervous system
• D. Damage to the urinary system

Correct answer: B

Rationale: The correct answer is B: Cognitive impairment. The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. Excessive growth (Choice A) is not a common complication of hypothyroidism in infants. Damage to the nervous system (Choice C) and damage to the urinary system (Choice D) are not typically associated with untreated hypothyroidism in infants.

2. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?

• A. Pain rated 7/10 on the pain scale.
• B. Mild swelling at the fracture site.
• C. Small amount of bleeding from the surgical site.
• D. Left extremity capillary refill greater than 5 seconds.

Correct answer: D

Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.

3. When assessing an adolescent with depression, what is the most important question for the nurse to ask?

• A. What is causing your feelings of depression?
• B. Have you ever thought about suicide?
• C. What actions can we take to improve your mood?
• D. Would you like your friends to come over?

Correct answer: B

Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.

4. What is the priority patient problem for the parents of a newborn born with cleft lip and palate?

• A. Parental role conflict
• B. Risk for delayed growth and development
• C. Risk for impaired attachment
• D. Anticipatory grieving

Correct answer: C

Rationale: The correct answer is C: Risk for impaired attachment. Parents of a newborn with cleft lip and palate may face challenges in bonding with their child due to the physical appearance, impacting attachment. Promoting bonding between parents and the infant is crucial in this situation. Choice A (Parental role conflict) is incorrect as it focuses on conflicting roles rather than the attachment issue. Choice B (Risk for delayed growth and development) is not the priority issue in this scenario as the immediate concern is establishing a healthy attachment. Choice D (Anticipatory grieving) is not the priority patient problem as it pertains more to the emotional response to an anticipated loss, which is not the primary concern at this stage.

5. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

• A. Low oxygen levels are present in the blood.
• B. High levels of carbon dioxide have accumulated in the blood.
• C. Increased bicarbonate levels are causing alkalosis.
• D. Respiratory rate is increased, causing hyperventilation.

Correct answer: B

Rationale: High levels of carbon dioxide in the blood lead to respiratory acidosis due to inadequate ventilation. The correct answer is B. In respiratory acidosis, the accumulation of carbon dioxide in the blood occurs due to inadequate exhalation, leading to acidosis. Choice A is incorrect as low oxygen levels are related to hypoxemia, not respiratory acidosis. Choice C is incorrect as increased bicarbonate levels would lead to alkalosis, not acidosis. Choice D is incorrect as an increased respiratory rate causing hyperventilation would actually help decrease carbon dioxide levels, not lead to respiratory acidosis.

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