Nursing Elites

1. When assessing a newborn infant with low set ears, short palpebral fissures, flat nasal bridge, and an indistinct philtrum, a priority maternal assessment by the nurse should be to ask about

• A. Alcohol use during pregnancy
• B. Usual nutritional intake
• C. Family genetic disorders
• D. Maternal and paternal ages

Correct answer: A

Rationale: The correct answer is A: Alcohol use during pregnancy. The physical features mentioned are indicative of fetal alcohol syndrome, a condition caused by maternal alcohol consumption during pregnancy. It is crucial for the nurse to inquire about alcohol use as it can help in diagnosing and managing the infant's condition. Choices B, C, and D are incorrect as they are not directly associated with the physical findings described in the newborn, which specifically point towards a potential history of alcohol exposure during pregnancy.

2. Which of the following patients should the home care nurse assess first?

• A. A 65-year-old male with known COPD and difficulty breathing after climbing a flight of stairs.
• B. A 78-year-old with CHF who has gained 4 lbs according to her tele-monitoring.
• C. A 50-year-old with bilateral leg swelling and difficulty walking.
• D. A 60-year-old with lower back pain.

Correct answer: A

Rationale: The correct answer is A. A patient with known COPD and difficulty breathing after physical exertion like climbing stairs requires immediate assessment by the nurse. This could indicate a potential exacerbation of COPD, which needs prompt intervention to prevent respiratory distress. Choices B, C, and D describe important patient situations that also require attention, but the urgency is higher with a COPD patient experiencing difficulty breathing.

3. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

• A. Pain related to periosteal injury
• B. Impaired mobility related to bleeding
• C. Parental anxiety related to knowledge deficit
• D. Injury related to intracranial hemorrhage

Correct answer: C

Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.

4. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has

• A. Achieved developmental milestones at an erratic rate
• B. Delay in musculoskeletal development
• C. Displayed difficulty with speech development
• D. Delay in achievement of most developmental milestones

Correct answer: D

Rationale: Children with AIDS often experience delays in achieving developmental milestones, affecting their overall growth and development. This delay can impact various areas of development, not limited to a specific aspect like musculoskeletal or speech development. While some children may achieve milestones at varying rates (choice A), the general trend is a delay in multiple milestones (choice D). Musculoskeletal development (choice B) and speech development (choice C) may be affected but are not as comprehensive as the delay in most developmental milestones.

5. A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of which task?

• A. Loss of control
• B. Insecurity
• C. Dependence
• D. Lack of trust

Correct answer: C

Rationale: A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of the task of dependence. Prolonged illness and confinement can lead to the development of dependence as the individual may become reliant on others for their care and needs. Choices A, B, and D are incorrect in this context. Loss of control, insecurity, and lack of trust are important factors to consider but are not directly related to the altered growth and development task of dependence due to illness and confinement.

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