Nursing Elites

1. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

• A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
• B. The chorea or movements are temporary and will eventually disappear.
• C. Permanent lifestyle changes are not needed to promote safety in the home.
• D. Consistent discipline is not directly related to controlling the movements.

Correct answer: B

Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course. Choices A, C, and D are incorrect because muscle tension, permanent lifestyle changes, and consistent discipline are not directly related to the resolution of chorea in rheumatic fever.

2. A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

• A. Inspect the client's face for edema.
• B. Ascertain the frequency of headaches.
• C. Evaluate for a history of cluster headaches.
• D. Observe and time the client's contractions.

Correct answer: A

Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.

3. Using Nägele's rule, what is the estimated date of delivery for a pregnant client who reports that the first day of her last menstrual period was August 2, 2006?

• A. April 25, 2007.
• B. May 9, 2007.
• C. May 29, 2007.
• D. June 2, 2007.

Correct answer: B

Rationale: Nägele's rule is used to estimate the date of delivery. It involves adding 7 days to the first day of the last menstrual period (August 2), which gives August 9. Then, subtracting 3 months from August 9, we arrive at May 9 of the following year as the estimated date of delivery. This makes choice B, 'May 9, 2007,' the correct answer. Choices A, C, and D are incorrect as they do not follow the correct calculation based on Nägele's rule.

4. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

• A. Perform a gestational age assessment.
• B. Obtain a drug screen for cocaine.
• C. Determine reactivity of neonatal reflexes.
• D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.

5. A child with glomerulonephritis is asking for strawberries. What should the nurse do?

• A. Allow the child to eat strawberries.
• B. Restrict the child's diet.
• C. Give the child a low-protein diet.
• D. Increase the child's fluid intake.

Correct answer: B

Rationale: In glomerulonephritis, it is crucial to restrict the child's diet, particularly avoiding foods high in potassium like strawberries. Potassium restriction is essential because impaired kidney function in glomerulonephritis can lead to potassium retention, potentially causing hyperkalemia. Therefore, the nurse should restrict the child's diet to manage their condition effectively.

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