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. 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.

3. A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?

• A. Hypertension
• B. Hyperglycemia
• C. Gingival hyperplasia
• D. Hypokalemia

Correct answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.

4. A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?

• A. Hepatitis C (HepC)
• B. Influenza type B (HIB)
• C. Measles, mumps, rubella (MMR)
• D. Diphtheria, tetanus, pertussis (DTaP)

Correct answer: C

Rationale: The correct answer is C: Measles, mumps, rubella (MMR). MMR vaccine is commonly included in precollege physicals to ensure students are protected against these diseases. Choice A, Hepatitis C (HepC), is incorrect as the standard vaccine for hepatitis given in childhood is Hepatitis B. Choice B, Influenza type B (HIB), is not typically administered during precollege physicals but is recommended for younger children. Choice D, Diphtheria, tetanus, pertussis (DTaP), is usually given in early childhood and not typically repeated during precollege physicals.

5. Which finding would be the most characteristic of an acute episode of reactive airway disease?

• A. Auditory gurgling
• B. Inspiratory laryngeal stridor
• C. Auditory expiratory wheezing
• D. Frequent dry coughing

Correct answer: C

Rationale: The correct answer is C: Auditory expiratory wheezing. Expiratory wheezing is a common sign of reactive airway disease, such as asthma, where airways are constricted, making it difficult to expel air from the lungs. Choices A, B, and D are incorrect as they are not typically associated with reactive airway disease. Auditory gurgling may suggest airway secretions or fluid accumulation, inspiratory laryngeal stridor indicates upper airway obstruction, and frequent dry coughing is more commonly seen in conditions like upper respiratory infections or postnasal drip.

Similar Questions