Nursing Elites

1. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.

• A. Regular developmental screening is important to avoid secondary developmental delays.
• B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
• C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
• D. Parent support groups are helpful for sharing strategies and managing health care issues.

Correct answer: C

Rationale: The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child's growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.

2. After Brandon is stabilized following his second myocardial infarction due to cocaine use, what collaborative process should begin to connect him with additional resources?

• A. Law enforcement for further prevention
• B. Social services for rehab
• C. Narcotics Anonymous
• D. Financial counselor to apply for assistance

Correct answer: B

Rationale: Following stabilization, it is essential to connect Brandon with additional resources to address his addiction. Social services are a crucial collaborative partner in this situation because they have access to community resources that can support Brandon's rehabilitation needs. While law enforcement may be involved in certain situations, their primary role is not to provide rehabilitation services. Narcotics Anonymous is a valuable support group but does not offer the comprehensive services that social services for rehab can provide. A financial counselor may be beneficial for addressing financial concerns, but the priority at this stage is to address Brandon's addiction through appropriate rehabilitation services.

3. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

4. A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

• A. Duchenne is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.
• B. Duchenne is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.
• C. Each child has a 1 in 4 (25%) chance of developing the disorder.
• D. Sons only have a 1 in 4 (25%) chance of developing the disorder.

Correct answer: A

Rationale: The correct answer is that Duchenne is an X-linked recessive disorder, meaning the affected gene is located on one of the two X chromosomes of a female carrier. If a son receives the X chromosome bearing the gene, he will develop the disease, giving him a 50% chance of being affected. Daughters, on the other hand, are not affected by Duchenne but have a 50% chance of being carriers since they inherit one copy of the defective gene from the mother. The other X chromosome is inherited from the father, who cannot be a carrier. Therefore, choice A is accurate. Choice B is incorrect because daughters do not develop the disease, and sons have a 50% chance of developing, not both having a 50% chance. Choice C is incorrect as it does not consider the X-linked inheritance pattern of Duchenne. Choice D is inaccurate as it incorrectly states that only sons have a 25% chance of developing the disorder, omitting the carrier status of daughters.

5. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?

• A. Do you mean your boyfriend?
• B. Do you mean your boyfriend?
• C. No one will ever hurt you again.
• D. Tell me more about what happens when he gets angry.

Correct answer: D

Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.

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