Nursing Elites

1. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

• A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
• B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
• C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
• D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.

Correct answer: C

Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.

2. A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following should the nurse recommend to the client as an appropriate sweetener?

• A. Corn syrup
• B. Natural honey
• C. Nonnutritive sugar substitute
• D. Agave nectar

Correct answer: C

Rationale: Nonnutritive sugar substitutes are suitable for individuals with diabetes, such as type 1 diabetes mellitus, as they do not affect blood glucose levels. Corn syrup and agave nectar contain high levels of sugar that can spike blood glucose levels, making them unsuitable for diabetes management. While natural honey is a natural sweetener, it can still impact blood sugar levels and is not the optimal choice for individuals with diabetes.

3. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?

• A. Bleeding time
• B. Hemoglobin and hematocrit
• C. White blood cells
• D. Platelets

Correct answer: B

Rationale: Corrected Hemoglobin and hematocrit levels should be monitored closely after blood transfusions to assess the effectiveness and identify any complications. Monitoring hemoglobin and hematocrit levels helps evaluate the patient's oxygen-carrying capacity and blood volume. While platelets are crucial for clotting, they are not typically affected immediately after a blood transfusion. White blood cell count monitoring is more relevant in assessing infection or immune response, not directly related to a blood transfusion. Bleeding time measures platelet function, which is not the primary concern immediately after a blood transfusion.

4. A healthcare professional assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

• A. Flaccid paralysis
• B. Pupils fixed and dilated
• C. Diminished spinal reflexes
• D. Reduced sensory responses

Correct answer: B

Rationale: The correct answer is B: Pupils fixed and dilated. Fixed and dilated pupils are a critical neurological sign that indicates severe neurological damage or brain herniation, posing a significant concern for the patient's condition. Flaccid paralysis (choice A) typically indicates lower motor neuron injury, while diminished spinal reflexes (choice C) and reduced sensory responses (choice D) may suggest various neurological issues but are not as acutely concerning as fixed and dilated pupils in this scenario.

5. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?

• A. Side-lying on the left with the head elevated 10 degrees
• B. Side-lying on the left with the head elevated 35 degrees
• C. Side-lying on the right with the head elevated 10 degrees
• D. Side-lying on the right with the head elevated 35 degrees

Correct answer: A

Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.

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