Nursing Elites

1. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. order an immediate electrocardiogram
• B. count the radial pulse every 1 minute for five times
• C. count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate
• D. have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, an important nursing responsibility is to count the apical pulse for 1 full minute and then compare this rate with the radial pulse rate. This method helps in identifying dysrhythmias as it allows for a direct comparison of the heart's rhythm at two different pulse points. Ordering an immediate electrocardiogram (Choice A) may be necessary but should not be the first step. Counting the radial pulse multiple times (Choice B) is not as accurate as comparing rates directly. Having someone else take the radial pulse simultaneously (Choice D) may introduce errors and inconsistencies in the measurement.

2. Parents of a sick infant talk with a nurse about their baby. One parent says, “I am so upset; I didn’t realize our baby was ill.” What major indication of illness in an infant should the nurse explain to the parent?

• A. Grunting respirations
• B. Excessive perspiration
• C. Longer periods of sleep
• D. Crying immediately after feedings

Correct answer: C

Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.

3. A school nurse is educating parents of school-age children on the significance of immunizations for childhood communicable diseases. What preventable disease may lead to the complication of encephalitis?

• A. Varicella (Chickenpox)
• B. Scarlet fever
• C. Poliomyelitis
• D. Whooping cough

Correct answer: A

Rationale: The correct answer is A: Varicella (Chickenpox). Varicella can lead to the complication of encephalitis, characterized by brain inflammation. Encephalitis is a known complication of chickenpox in rare cases. Scarlet fever (choice B) is caused by Streptococcus bacteria and does not typically result in encephalitis. Poliomyelitis (choice C) primarily affects the spinal cord and does not lead to encephalitis. Whooping cough (choice D) can cause severe coughing spells but does not directly result in encephalitis.

4. The nurse is assessing a 3-year-old boy whose parents brought him to the clinic when they noticed that the right side of his abdomen was swollen. What finding would suggest this child has a neuroblastoma?

• A. The child has a maculopapular rash on his palms.
• B. The parents report that their son is vomiting and not eating well.
• C. The parents report that their son is irritable and not gaining weight.
• D. Auscultation reveals wheezing with diminished lung sounds.

Correct answer: B

Rationale: Vomiting and poor appetite can be symptoms of neuroblastoma, a malignancy that affects the adrenal glands and sympathetic nervous system. A maculopapular rash on the palms (Choice A) is not typically associated with neuroblastoma. Irritability and poor weight gain (Choice C) may be non-specific findings and do not specifically point towards neuroblastoma. Auscultation findings of wheezing with diminished lung sounds (Choice D) are more indicative of respiratory conditions rather than neuroblastoma.

5. The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity due to cast and location.
• B. Deficient knowledge related to cast care.
• C. Risk for delayed development related to immobility.
• D. Self-care deficit related to immobility.

Correct answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity due to cast and location. When caring for a child with a long-leg hip spica cast, the priority nursing diagnosis is the risk for impaired skin integrity. This is because the child's limited mobility and the pressure from the cast can lead to skin breakdown and complications. Choice B is incorrect as while education is essential, it is not the priority when immediate physical risks are present. Choice C is incorrect because while immobility can impact development, the immediate concern is preventing complications from the cast. Choice D is incorrect as it focuses on self-care deficits rather than the physical risk of skin integrity issues.

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