Nursing Elites

1. Several types of seizures can occur in neonates. What is characteristic of clonic seizures?

• A. Apnea
• B. Tremors
• C. Extension of all four limbs
• D. Jerking that cannot be stopped by flexion of the affected limb

Correct answer: D

Rationale: Clonic seizures are characterized by slow, rhythmic, jerking movements that cannot be stopped by flexion of the affected limb. Therefore, the correct characteristic of clonic seizures is option D. Option A, apnea, is not characteristic of clonic seizures. Option B, tremors, does not describe clonic seizures accurately. Option C, extension of all four limbs, is not a typical feature of clonic seizures but rather seen in tonic seizures.

2. A 12-year-old girl has recently begun menstruating and is well into puberty. The child is visiting the health care provider today for a routine physical examination. Which finding should cause concern in the nurse?

• A. Breasts of slightly different sizes
• B. Irregular periods
• C. Vulvar irritation
• D. Supernumerary nipple

Correct answer: C

Rationale: Vulvar irritation may indicate an infection or other issues and should be further evaluated. In a pubescent girl, breasts of slightly different sizes and irregular periods are common variations of normal development. Supernumerary nipple, an extra nipple, is a benign condition that is not typically concerning during puberty.

3. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

• A. Suggestive of chronic pulmonary disease
• B. Suggestive of impending respiratory failure
• C. An abnormal finding warranting investigation
• D. A normal finding in infants younger than 1 year of age

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

4. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?

• A. Respond to name
• B. React to loud noise with Moro reflex
• C. Turn his or her head to side when sound is at ear level
• D. Locate sound by turning his or her head in a curving arc

Correct answer: B

Rationale: At 2 months, infants typically react to loud noises with the Moro reflex, a startle response that is normal at this stage of development.

5. Physiologically, the child compensates for fluid volume losses by which mechanism?

• A. Inhibition of aldosterone secretion
• B. Hemoconcentration to reduce cardiac workload
• C. Fluid shift from interstitial space to intravascular space
• D. Vasodilation of peripheral arterioles to increase perfusion

Correct answer: C

Rationale: In response to dehydration, the body compensates by shifting fluids from the interstitial spaces to the intravascular space to maintain blood pressure and perfusion to vital organs. Hemoconcentration and vasoconstriction are other compensatory mechanisms but are less immediate.

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