Nursing Elites

1. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

• A. Vesicular
• B. Bronchial
• C. Adventitious
• D. Bronchovesicular

Correct answer: A

Rationale: Vesicular breath sounds are normally heard over most of the lung fields, except near the trachea and main bronchi, where bronchial or bronchovesicular sounds may be heard.

2. The educator is teaching about the process of physical growth and development. Which of these describes the directional pattern from head to tail?

• A. Cephalodistal
• B. Cephalocaudal
• C. Proximodistal
• D. Proximocaudal

Correct answer: B

Rationale: Cephalocaudal development is the correct term that describes the directional pattern of growth from head to tail. This means that the head and upper body parts develop before the lower parts. Choice A, 'Cephalodistal,' refers to growth from the center of the body outward, not head to tail. Choice C, 'Proximodistal,' describes growth from the center of the body towards the extremities, not specifically from head to tail. Choice D, 'Proximocaudal,' is not a recognized term in the context of physical growth and development.

3. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?

• A. Hold feedings.
• B. Check gastric residuals before feedings.
• C. Take rectal temperature.
• D. Closely monitor abdominal distention.

Correct answer: D

Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.

4. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

• A. The infant responds to his own name.
• B. The infant localizes sounds by turning his head directly to the sound.
• C. The infant turns his head to the side when sound is made at the level of the ear.
• D. The infant locates sound by turning his head to the side and then looking up or down.

Correct answer: C

Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.

5. What information should the nurse include when teaching an adolescent with Crohn disease (CD)?

• A. How to cope with stress and adjust to chronic illness
• B. Preparation for surgical treatment and cure of CD
• C. Nutritional guidance and prevention of constipation
• D. Prevention of spread of illness to others and principles of high-fiber diet

Correct answer: A

Rationale: Teaching about coping with stress and adjusting to chronic illness is crucial for adolescents with Crohn disease. CD is a chronic condition with no cure, so focusing on managing the disease, stress, and diet is essential for improving the adolescent's quality of life. Choice B is incorrect because Crohn disease cannot be cured surgically. Choice C is relevant but not as essential as coping with stress and chronic illness. Choice D is not a priority in teaching an adolescent with Crohn disease as it mainly focuses on preventing the spread of illness to others, which is not a significant concern with CD, and high-fiber diets may not always be suitable for individuals with this condition.

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