Nursing Elites

1. A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

• A. Low-grade fever.
• B. Muscle atrophy.
• C. Hematuria.
• D. Joint pain.

Correct answer: C

Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.

2. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?

• A. A history of diarrhea following each feeding
• B. Gastric pain evidenced by vigorous crying
• C. Poor appetite due to a poor sucking reflex
• D. An olive-shaped mass right of the midline

Correct answer: D

Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.

3. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?

• A. Cerebral palsy
• B. Hydrocephalus
• C. Meningitis
• D. Neuroblastoma

Correct answer: B

Rationale: Hydrocephalus is the additional congenital malformation expected in 80% of infants with a myelomeningocele. Myelomeningocele is commonly associated with hydrocephalus due to the abnormal accumulation of cerebrospinal fluid in the brain. Cerebral palsy (Choice A) is a motor disorder but not typically associated with myelomeningocele. Meningitis (Choice C) is an infection of the meninges and is not a congenital malformation. Neuroblastoma (Choice D) is a type of cancer that originates in immature nerve cells and is not a typical association with myelomeningocele.

4. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?

• A. Assist with referral to specialized education.
• B. Support the child with independent toileting.
• C. Assist the child to develop effective communication.
• D. Encourage the child to ambulate independently.

Correct answer: C

Rationale: The correct answer is C: 'Assist the child to develop effective communication.' Children with cerebral palsy often face challenges with communication skills. Therefore, priority nursing interventions aim to help them improve their communication abilities. Choice A is incorrect because while education is important, the priority for a child with cerebral palsy is to address immediate needs. Choice B is incorrect as toileting, although important, is not the priority in this case. Choice D is incorrect as ambulation may not be feasible or the most critical concern for a child with cerebral palsy.

5. A client with chronic kidney disease is advised to follow a low-phosphorus diet. Which food should the client avoid?

• A. Milk
• B. Apples
• C. Carrots
• D. Rice

Correct answer: A

Rationale: Correct Answer: Milk. Milk is high in phosphorus and should be avoided in a low-phosphorus diet for clients with chronic kidney disease. Choice B (Apples), C (Carrots), and D (Rice) are not significant sources of phosphorus and can be included in moderation in a low-phosphorus diet. Apples and carrots are generally considered healthy choices for most individuals, while rice is a staple food that is low in phosphorus and can be part of a renal diet.

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