Nursing Elites

1. A client who is at 24 weeks of gestation is receiving teaching about expected changes during pregnancy. Which of the following information should the nurse include?

• A. Your stomach will empty rapidly
• B. You should expect your uterus to double in size
• C. You should anticipate nasal stuffiness
• D. Your nipples will become lighter in color

Correct answer: C

Rationale: Nasal stuffiness is a common symptom during pregnancy due to increased blood flow and hormonal changes. This symptom is caused by the increased blood volume and hormonal changes that lead to swelling of the nasal passages. Choices A, B, and D are incorrect. Stomach emptying rate does not significantly change during pregnancy; the uterus does not double in size at 24 weeks but rather grows steadily, and nipples typically darken in color due to increased pigmentation.

2. A client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant?

• A. Morning sickness.
• B. Breast tenderness.
• C. Amenorrhea.
• D. Hegar's sign.

Correct answer: D

Rationale: Hegar's sign, which is a softening of the lower uterine segment, is considered a probable sign of pregnancy as it indicates changes in the cervix and uterus that occur during pregnancy. Amenorrhea, the absence of menstruation, is a common early sign of pregnancy but can also be due to other factors. Morning sickness, nausea and vomiting, can be a sign of early pregnancy but is not as specific as Hegar's sign. Breast tenderness is a common symptom in early pregnancy due to hormonal changes, but it is not as definitive as Hegar's sign in indicating pregnancy.

3. How many pairs of autosomes does a human zygote contain?

• A. 46
• B. 44
• C. 23
• D. 22

Correct answer: D

Rationale: A human zygote contains 22 pairs of autosomes and one pair of sex chromosomes, totaling 46 chromosomes. Therefore, the correct answer is 22. Choices A, B, and C are incorrect because they do not accurately represent the number of autosomes in a human zygote. Option A (46) represents the total number of chromosomes in a human zygote, not the number of autosomes. Option B (44) is incorrect as it does not account for the correct number of autosomes. Option C (23) is inaccurate since it represents the total number of chromosomes in a human gamete, not the number of autosomes in a zygote.

4. Matt is a 36-year-old male. In the past year, he has noticed that his limbs sometimes move on their own, and he has also started having trouble remembering things and doing simple calculations. Matt’s father and grandfather were also known to have similar problems during their adulthood. Matt is most likely suffering from:

• A. Phenylketonuria (PKU).
• B. Cystic fibrosis.
• C. Turner syndrome.
• D. Huntington’s disease (HD).

Correct answer: D

Rationale: Matt is exhibiting symptoms typical of Huntington’s disease (HD), a hereditary condition characterized by involuntary movements, cognitive impairment, and behavioral changes. The fact that Matt's father and grandfather had similar issues supports the genetic nature of the disease. Phenylketonuria (PKU) is a metabolic disorder that affects amino acid metabolism, not presenting with the symptoms described. Cystic fibrosis primarily affects the respiratory and digestive systems, not causing the neurological symptoms described. Turner syndrome is a genetic condition affecting females and is not associated with the symptoms described in the case of Matt.

5. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman’s vital signs, which finding would be of greatest concern to the nurse?

• A. Temperature 37.9°C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg.
• B. Temperature 37.4°C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg.
• C. Temperature 38°C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg.
• D. Temperature 36.8°C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg.

Correct answer: A

Rationale: An estimated blood loss (EBL) of 1500 ml following a vaginal birth is significant and can lead to hypovolemia. The vital signs provided in option A (Temperature 37.9°C, heart rate 120 bpm, respirations 20 breaths per minute, and blood pressure 90/50 mm Hg) indicate tachycardia and hypotension, which are concerning signs of hypovolemia due to excessive blood loss. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, and hypotension indicates inadequate perfusion. Options B, C, and D do not exhibit the same level of concern for hypovolemia. Option B shows tachypnea, which can be a result of pain or anxiety postpartum. Option C and D have vital signs within normal limits, which are not indicative of the body's response to significant blood loss.

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