Nursing Elites

1. When caring for a child with Reye's Syndrome, which action should the nurse give the highest priority?

• A. Monitor intake and output
• B. Provide good skin care
• C. Assess level of consciousness
• D. Assist with range of motion

Correct answer: C

Rationale: Assessing the level of consciousness is crucial when caring for a child with Reye's Syndrome. Changes in neurological status can indicate deterioration of the condition, necessitating immediate medical attention. Monitoring intake and output is important but not the highest priority compared to assessing the child's level of consciousness. Providing good skin care and assisting with range of motion are also important aspects of care but take a lower priority than assessing the child's neurological status in this critical condition.

2. When the Public Health Nurse assesses needs and plans health interventions for a group of people in coordination with other health professionals, they are demonstrating which of the following features of community health nursing:

• A. CHN involves interdisciplinary collaboration
• B. The use of an epidemiologic approach is an essential part of nursing practice
• C. CHN is oriented towards populations
• D. CHN encourages the client's participation in determining their own health

Correct answer: A

Rationale: The correct answer is A. Interdisciplinary collaboration is a fundamental feature of community health nursing. In this scenario, the nurse works with other health professionals to assess needs and plan interventions for a group of people, emphasizing the importance of teamwork and cooperation. Choice B is incorrect because while epidemiology plays a role in community health nursing, it is not the primary focus of this particular situation. Choice C is incorrect as it describes the population-focused nature of community health nursing, which is related but not directly demonstrated in the given scenario. Choice D is incorrect because while client participation is essential in community health nursing, it is not the primary feature demonstrated in the scenario provided.

3. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client

• A. ''Be sure to eat a fat-free diet until the test.''
• B. ''Do not eat or drink anything but water for 12 hours before the blood test.''
• C. ''Have the blood drawn within 2 hours of eating breakfast.''
• D. ''Stay at the laboratory so 2 blood samples can be drawn an hour apart.''

Correct answer: B

Rationale: Fasting for at least 12 hours is necessary before a cholesterol and triglyceride test to ensure accurate results by avoiding fluctuations that can occur after eating. Choice A is incorrect because a fat-free diet is not required; fasting is. Choice C is incorrect as it suggests having the test right after eating, which can affect the results. Choice D is incorrect as there is no need to stay at the laboratory for 2 blood samples unless specifically instructed by a healthcare provider.

4. In the immediate postoperative period for a cleft lip repair in a 2-month-old infant, which nursing approach should be the priority?

• A. Remove protective arm devices one at a time for short periods with supervision
• B. Initiate oral feedings when alert
• C. Introduce the parents to the suture line cleansing protocol
• D. Position the infant on the back after feedings throughout the day

Correct answer: A

Rationale: The correct nursing approach in the immediate postoperative period for a cleft lip repair in an infant is to remove protective arm devices one at a time for short periods with supervision. This approach helps prevent injury to the surgical site while ensuring the infant's comfort and safety. Choice B is incorrect as initiating oral feedings immediately after surgery may not be appropriate and could compromise the surgical site. Choice C is incorrect as introducing parents to the suture line cleansing protocol is important but not the immediate priority. Choice D is incorrect as positioning the infant on the back after feedings is not specific to the immediate postoperative period for a cleft lip repair.

5. What is a priority goal of involuntary hospitalization of the severely mentally ill client?

• A. Re-orientation to reality
• B. Elimination of symptoms
• C. Protection from harm to self or others
• D. Development of self-care skills

Correct answer: C

Rationale: The correct answer is C: 'Protection from harm to self or others.' Involuntary hospitalization is primarily aimed at ensuring the safety of the individual and others. Re-orientation to reality (choice A) may be a goal of treatment but not the primary goal of involuntary hospitalization. Elimination of symptoms (choice B) and development of self-care skills (choice D) are important aspects of treatment but are secondary to the immediate priority of ensuring safety in cases of severe mental illness.

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