Nursing Elites

1. When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?

• A. Impaired body image
• B. Skin impairment
• C. Nutritional deficit
• D. Injury

Correct answer: B

Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.

2. The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?

• A. The causes of major depression are unknown.
• B. Major affective disorders in parents increase depression in children.
• C. Boys are more likely than girls to be depressed.
• D. The prevalence rate is higher in prepubescent children.

Correct answer: B

Rationale: The correct answer is B because while the exact causes of depression in children are not fully understood, research indicates that children are more likely to experience depression if their parents have a major affective disorder. Choice A is incorrect because it suggests that the causes of major depression are entirely unknown, which is not accurate. Choice C is incorrect as there is no conclusive evidence that boys are more likely than girls to be depressed. Choice D is incorrect as the prevalence rate of depression is not necessarily higher in prepubescent children specifically.

3. The healthcare provider is assessing a client with a chest tube. Which finding indicates that the chest tube is functioning properly?

• A. Continuous bubbling in the water seal chamber
• B. Tidaling in the water seal chamber
• C. Absence of drainage in the collection chamber
• D. Fluid level in the suction control chamber is below the prescribed level

Correct answer: B

Rationale: Tidaling in the water seal chamber indicates proper chest tube function. Tidaling refers to the rise and fall of fluid in the water seal with inhalation and exhalation, demonstrating the patency of the system. Continuous bubbling (Choice A) in the water seal chamber indicates an air leak. Absence of drainage in the collection chamber (Choice C) is not a desired finding as it suggests no drainage is occurring. A fluid level below the prescribed level in the suction control chamber (Choice D) may indicate inadequate suction.

4. Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?

• A. Risk for infection related to thrombolysis.
• B. Risk for fluid volume deficit related to thrombolysis.
• C. Risk for impaired skin integrity related to thrombolysis.
• D. Risk for injury related to effects of thrombolysis.

Correct answer: D

Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.

5. Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?

• A. Potential for injury related to vertigo.
• B. Alteration in comfort due to ear pain.
• C. Impaired skin integrity due to immobility.
• D. Anxiety due to fear of falling.

Correct answer: A

Rationale: The correct answer is A. When caring for a client with Meniere’s disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere’s disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.

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