Nursing Elites

1. Which nursing action promotes psychosocial development for a newborn?

• A. Washing hands before holding the newborn
• B. Measuring the newborn using an approved length board
• C. Weighing the newborn on the same scale during hospitalization
• D. Placing the newborn in the mother's arms during the first hour of life

Correct answer: D

Rationale: Placing the newborn in the mother's arms during the first hour of life is a crucial nursing action that promotes psychosocial development by fostering bonding between the newborn and the mother. This skin-to-skin contact enhances emotional attachment, facilitates breastfeeding initiation, and provides a sense of security for the newborn. It helps in regulating the newborn's temperature, heart rate, and breathing, promoting overall well-being. Washing hands before holding the newborn is essential for infection prevention and control to maintain the newborn's health and safety. Measuring the newborn using an approved length board and weighing the newborn on the same scale during hospitalization are assessments aimed at monitoring the newborn's physical growth and development, rather than directly promoting psychosocial well-being.

2. A client who is newly diagnosed with multiple sclerosis is obviously upset and asks, 'Am I going to die?' Which response would the nurse make?

• A. Most individuals with your disease live a normal life span.
• B. Is your family here? I would like to explain your disease to all of you.
• C. The prognosis varies, as most individuals have remissions and exacerbations.
• D. Why don't you speak with your health care provider to get more details?

Correct answer: C

Rationale: The most appropriate response to the client's question regarding their prognosis is to acknowledge the variable nature of multiple sclerosis by stating that 'The prognosis varies, as most individuals have remissions and exacerbations.' This response provides realistic information while offering some hope. Choice A ('Most individuals with your disease live a normal life span.') gives false reassurance as repeated exacerbations may affect life span. Choice B ('Is your family here? I would like to explain your disease to all of you.') does not directly address the client's question and involves the family unnecessarily. Choice D ('Why don't you speak with your health care provider to get more details?') deflects the responsibility and does not address the client's immediate concerns about their prognosis.

3. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose × Volume on hand) / Dose on hand). In this case, it would be (4 mg × 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.

4. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

• A. Do not worry. Epilepsy can be treated with medications.
• B. The seizure may or may not mean your child has epilepsy.
• C. Since this was the first convulsion, it may not happen again.
• D. Long-term treatment will prevent future seizures.

Correct answer: B

Rationale: The correct response is, 'The seizure may or may not mean your child has epilepsy.' There are various potential causes for a childhood seizure, such as fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic reasons. It's essential not to jump to conclusions about epilepsy based on one seizure. Options A, C, and D provide premature or inaccurate information. Option A may give false reassurance without proper evaluation, option C assumes one seizure guarantees no recurrence, and option D oversimplifies treatment outcomes.

5. Which defense mechanism would the nurse conclude a female client with obsessive-compulsive disorder, who washes her hands more than 20 times a day, is using to ease anxiety?

• A. Undoing
• B. Projection
• C. Introjection
• D. Displacement

Correct answer: A

Rationale: The correct answer is 'Undoing.' Undoing is a defense mechanism where the individual tries to negate a previous act to relieve guilt or anxiety. In this case, the client washing her hands excessively is trying to 'undo' perceived contamination or guilt associated with not washing. Projection (choice B) involves attributing one's own unacceptable thoughts or impulses to others, which is not demonstrated in this scenario. Introjection (choice C) is the process of internalizing beliefs or values of others, which is also not applicable in this context. Displacement (choice D) involves redirecting emotions from one target to another, which does not align with the client's behavior of handwashing as a response to anxiety in this case.

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