Nursing Elites

1. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?

• A. A normal finding
• B. A sign of a possible visual defect and a need for vision screening
• C. An abnormal finding requiring referral to an ophthalmologist
• D. A sign of small hemorrhages, which usually resolve spontaneously

Correct answer: A

Rationale: A brilliant, uniform red reflex in both eyes is a normal finding, indicating that the retina is healthy and there are no significant obstructions in the visual pathway.

2. What term is appropriate terminology to use for an infant whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

• A. Postterm
• B. Postmature
• C. Low birth weight
• D. Small for gestational age

Correct answer: D

Rationale: The correct answer is D, 'Small for gestational age.' A small for gestational age, or small-for-date, infant is any child whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Choices A and B, 'Postterm' and 'Postmature,' refer to infants born after 42 weeks of gestational age regardless of birth weight, and do not specifically address growth rate. Choice C, 'Low birth weight,' refers to infants with a birth weight less than 2500 g (5.5 pounds) regardless of gestational age, which is a different classification compared to being small for gestational age.

3. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.)

• A. Buying clothes for the patients
• B. Showing favoritism toward a patient
• C. All
• D. Spending off-duty time with patients and families

Correct answer: C

Rationale: Overinvolvement includes personal actions like buying clothes, showing favoritism, and spending off-duty time with patients, which can blur professional boundaries.

4. What is the primary consideration of susceptibility to infections in neonates?

• A. Increased humoral immunity
• B. Overwhelming anti-inflammatory response
• C. Diminished nonspecific and specific immunity
• D. Excessive levels of immunoglobulin A and immunoglobulin M

Correct answer: C

Rationale: The primary consideration of susceptibility to infections in neonates is their diminished nonspecific and specific immunity. Neonates lack the ability to mount a robust immune response, making them vulnerable to infections. Choice A is incorrect because neonates do not have increased humoral immunity; rather, their humoral immunity is diminished. Choice B is incorrect as neonates do not have an overwhelming anti-inflammatory response; instead, their immune responses are generally weakened. Choice D is incorrect because neonates have diminished or absent levels of immunoglobulin A and immunoglobulin M, contributing to their susceptibility to infections.

5. When assessing a preschooler's chest, what should the nurse expect?

• A. Respiratory movements to be chiefly thoracic
• B. Anteroposterior diameter to be equal to the transverse diameter
• C. Retraction of the muscles between the ribs on respiratory movement
• D. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing

Correct answer: D

Rationale: In a preschooler, chest movement should be symmetric and coordinated with breathing, indicating healthy respiratory function.

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