Nursing Elites

1. Which of the following is a fatal genetic neurologic disorder whose onset is in middle age?

• A. Tay-Sachs disease
• B. Duchenne muscular dystrophy
• C. Hemophilia
• D. Huntington’s disease

Correct answer: D

Rationale: Huntington's disease is a fatal genetic neurologic disorder characterized by progressive nerve cell degeneration in the brain. It typically manifests in middle age with symptoms such as involuntary movements, cognitive decline, and psychiatric disturbances. Tay-Sachs disease (Choice A) is a genetic disorder that primarily affects the nervous system in early childhood, not middle age. Duchenne muscular dystrophy (Choice B) is a genetic disorder that primarily affects muscle function and usually presents in early childhood. Hemophilia (Choice C) is a genetic disorder related to blood clotting, and its onset is not typically in middle age.

2. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?

• A. Administer oxygen by mouth at 2L/min
• B. Gradually warm the infant under a radiant heat source
• C. Notify the pediatrician of the infant's vital signs
• D. Perform a heel-stick to maintain blood glucose levels

Correct answer: B

Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.

3. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7-pound, 10-ounce (3220-gram) infant. Which information should the nurse provide to the client about these findings?

• A. The uterus should be firm to prevent an intrauterine infection.
• B. Both the lower uterine segment and the fundus must be massaged.
• C. A firm uterus prevents the endometrial lining from being sloughed.
• D. Clots may form inside a boggy uterus and need to be expelled.

Correct answer: D

Rationale: After childbirth, a boggy uterus indicates poor uterine tone, which can lead to the formation of clots. Massaging the fundus helps the uterus contract and expel clots, reducing the risk of postpartum hemorrhage. Choices A, B, and C are incorrect because the main concern with a boggy uterus is the risk of clot formation and postpartum hemorrhage, not solely preventing intrauterine infection, massaging the lower uterine segment, or preventing the endometrial lining from sloughing.

4. Twenty-year-old Jack is extremely tall and has very thick facial hair. Most of his male secondary sex characteristics are also more pronounced than men of his age. In this scenario, Jack is most likely:

• A. an XYY male.
• B. diagnosed with Klinefelter syndrome.
• C. an XXY male.
• D. diagnosed with Down syndrome.

Correct answer: A

Rationale: The correct answer is A: an XYY male. Individuals with XYY syndrome often exhibit increased height and more pronounced secondary male characteristics, such as thick facial hair. Choice B, Klinefelter syndrome (XXY), typically presents with less prominent male secondary sex characteristics due to the presence of an extra X chromosome. Choice C, XXY male, refers to Klinefelter syndrome, which does not align with the description of Jack having more pronounced male secondary sex characteristics. Choice D, Down syndrome, is caused by a trisomy of chromosome 21 and is not associated with the physical characteristics described in the scenario.

5. A client is in the second stage of labor. Which of the following manifestations should the nurse expect?

• A. The client expels the placenta
• B. The client experiences gradual dilation of the cervix
• C. The client begins having regular contractions
• D. The client delivers the newborn

Correct answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the client delivers the newborn. The expulsion of the placenta occurs during the third stage of labor, not the second stage. Regular contractions typically begin in the first stage of labor, not the second. Gradual dilation of the cervix occurs during the first stage of labor, specifically during the active phase.

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