Nursing Elites

1. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

• A. Nevus simplex
• B. Caput succedaneum
• C. Cephalohematoma
• D. Erythema toxicum

Correct answer: B

Rationale: Caput succedaneum is the correct answer. It is the swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction. Nevus simplex (Choice A) is a pink or red birthmark that is flat and usually fades on its own. Cephalohematoma (Choice C) is a collection of blood between a baby's skull and the periosteum, often caused by birth trauma. Erythema toxicum (Choice D) is a common rash in newborns that is benign and typically resolves on its own. In this case, the description of swelling over the newborn's head crossing the suture line is characteristic of caput succedaneum, which is a common finding in newborns after vaginal delivery.

2. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?

• A. 1 packet of reconstituted dry onion soup
• B. 3 oz of lean cured ham
• C. 3 oz of chicken breast
• D. 1/2 cup of canned baked beans

Correct answer: C

Rationale: A low sodium diet is recommended for a client who has hypertension. Therefore, the nurse should recommend 3 oz of chicken breast as the best choice for the client's diet because it contains 30 – 90 mg of sodium. Choice A, 1 packet of reconstituted dry onion soup, and Choice B, 3 oz of lean cured ham, are high in sodium content, which is not suitable for a client with hypertension. Choice D, 1/2 cup of canned baked beans, is also high in sodium, making it a less suitable choice compared to 3 oz of chicken breast.

3. A healthcare professional is assessing a client for signs of infection. Which of the following findings should the healthcare professional look for?

• A. Increased energy
• B. Fever
• C. Improved appetite
• D. Stable weight

Correct answer: B

Rationale: Corrected Question: A healthcare professional is assessing a client for signs of infection. The correct answer is 'Fever.' Fever is a common sign of infection and indicates an immune response to an invading pathogen. Increased energy (Choice A) is not typically associated with infection, as the body often feels fatigued when fighting an infection. Improved appetite (Choice C) and stable weight (Choice D) are not specific signs of infection and may not necessarily indicate the presence of an infectious process. Therefore, the healthcare professional should focus on monitoring for fever as a key indicator of infection.

4. A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?

• A. We will place the baby on its back to sleep
• B. We will give the baby a pacifier at bedtime
• C. We will keep the baby's crib free of blankets and toys
• D. We will leave the baby's diaper off to prevent diaper rash

Correct answer: D

Rationale: The correct answer is D. Leaving the baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash. Choices A, B, and C are correct as placing the baby on its back to sleep, giving the baby a pacifier at bedtime, and keeping the baby's crib free of blankets and toys are appropriate measures to ensure the newborn's safety and reduce the risk of Sudden Infant Death Syndrome (SIDS).

5. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?

• A. Feelings of dread
• B. Rapid speech
• C. Purposeless activity
• D. Heightened perceptual field

Correct answer: D

Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.

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