Nursing Elites

1. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?

• A. Poor appetite
• B. Reduction of edema
• C. Restriction to bed rest
• D. Increased potassium intake

Correct answer: B

Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.

2. The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia?

• A. Maternally derived iron stores are depleted in the first 2 months.
• B. Fetal hemoglobin results in a shortened survival of red blood cells.
• C. The production of adult hemoglobin decreases in the first year of life.
• D. Low levels of fetal hemoglobin depress the production of erythropoietin.

Correct answer: B

Rationale: Physiologic anemia is caused by the transition from fetal to adult hemoglobin, with fetal hemoglobin having a shorter lifespan, leading to a temporary decrease in red blood cells.

3. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?

• A. Closed anterior fontanel
• B. Sunken anterior fontanel
• C. Bulging anterior fontanel
• D. Pulsating anterior fontanel

Correct answer: D

Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.

4. You are providing a home health care assessment for a very low-income mother with three young children under 5 who all appear to be at nutritional risk. Which program would you refer them to in an attempt to reduce the risk and safeguard the health of this family?

• A. Division of Maternal and Child Health
• B. Medicaid
• C. Supplemental Food Program for Women, Infants, and Children
• D. The State Children’s Health Insurance Program

Correct answer: C

Rationale: The correct answer is C, the Supplemental Food Program for Women, Infants, and Children (WIC). WIC provides nutritional assistance to low-income pregnant women, breastfeeding women, and children under 5. The Division of Maternal and Child Health (Choice A) focuses on promoting the health of mothers and children but does not provide direct nutritional assistance. Medicaid (Choice B) is a health insurance program for low-income individuals but does not specifically address nutritional needs. The State Children’s Health Insurance Program (Choice D) provides health insurance for children in low-income families but does not offer nutritional support like WIC does.

5. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

• A. Use the small cuff
• B. Use the large cuff
• C. Use either cuff using the palpation method
• D. Wait to take the blood pressure until a proper cuff can be located

Correct answer: D

Rationale: It is essential to use the correct cuff size for accurate blood pressure readings; if the proper size is not available, it's best to wait until it can be obtained.

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