Nursing Elites

1. Warning signs that indicate dehydration include all EXCEPT:

• A. Poor skin turgor
• B. Increased urine output
• C. Tachycardia
• D. Eager to drink

Correct answer: B

Rationale: The correct answer is B. Increased urine output is not a warning sign of dehydration; it typically decreases with dehydration. Dehydration often presents with poor skin turgor, tachycardia, and an increased sensation of thirst (eager to drink) as the body tries to compensate for fluid loss. Choices A, C, and D are all correct warning signs of dehydration. Poor skin turgor is a result of decreased skin elasticity due to fluid loss. Tachycardia, an elevated heart rate, can be a compensatory mechanism to maintain cardiac output in dehydration. Feeling eager to drink is a common symptom of dehydration as the body attempts to restore fluid balance.

2. How would you classify a child at two years of age who has fast breathing without chest indrawing or stridor when calm?

• A. Very severe disease
• B. Pneumonia
• C. No pneumonia
• D. Local infection

Correct answer: B

Rationale: In pediatric clinical assessment, a child at two years of age with fast breathing but without chest indrawing or stridor when calm is classified as having pneumonia. Fast breathing in this context is a key symptom used in the Integrated Management of Childhood Illness (IMCI) guidelines to diagnose pneumonia in children under five years old. The absence of chest indrawing or stridor when the child is calm helps differentiate this case from other respiratory conditions, making pneumonia the likely classification. Choices A, C, and D are incorrect. 'Very severe disease' is too broad and not specific to the symptoms described. 'No pneumonia' is also incorrect as the symptoms match the presentation of pneumonia. 'Local infection' is too vague and does not specifically address the respiratory symptoms observed.

3. When assessing a geriatric patient who has possibly experienced an acute ischemic stroke, which of the following questions would be MOST appropriate to ask?

• A. When did you first notice the symptoms?
• B. Do you have a history of high blood pressure?
• C. What medications do you take and why?
• D. Have you previously had a heart attack?

Correct answer: A

Rationale: The most appropriate question to ask when assessing a geriatric patient who may have experienced an acute ischemic stroke is when the symptoms were first noticed. This information is crucial for determining the time window for potential treatments like thrombolytic therapy, as prompt intervention is necessary for stroke management. Option B is not as relevant in the acute assessment of stroke, though important for overall health history. Option C is important but may not be as time-sensitive as determining symptom onset. Option D focuses on a different cardiac event, not directly related to the current concern of a possible stroke.

4. The caregiver is teaching a new parent about signs of adequate breastfeeding. Which statement by the parent indicates understanding?

• A. My baby should have a bowel movement once a week.
• B. My baby should wet at least six diapers a day.
• C. My baby should feed for 5 minutes on each breast.
• D. My baby should sleep through the night without waking up to feed.

Correct answer: B

Rationale: Wetting at least six diapers a day is a key indicator of adequate breastfeeding as it shows that the baby is properly hydrated and receiving enough milk.

5. Before drying off the newborn after birth, which assessment finding should the healthcare professional document to ensure an accurate gestational rating on the Ballard gestational assessment tool?

• A. Amount and area of vernix coverage
• B. Creases on the sole
• C. Size of the areola
• D. Body surface temperature

Correct answer: A

Rationale: To ensure an accurate gestational rating on the Ballard gestational assessment tool, healthcare professionals should document the amount and area of vernix coverage before drying the newborn. Drying the baby after birth could disturb the vernix, potentially affecting the gestational age assessment. Assessing and documenting the vernix coverage beforehand enables a more precise evaluation using the Ballard gestational assessment tool. Choices B, C, and D are incorrect as they are not directly related to gestational rating on the Ballard assessment tool.

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