Nursing Elites

1. A client with rheumatoid arthritis has elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

• A. Evidence of spread of the disease to the kidney.
• B. Confirmation of the autoimmune disease process.
• C. Representative of a decline in the client's condition.
• D. Indication of the onset of joint degeneration.

Correct answer: B

Rationale: The correct interpretation of elevated serum rheumatoid factor in a client with rheumatoid arthritis is confirmation of the autoimmune disease process. Rheumatoid factor is a marker for autoimmune activity, thus confirming the diagnosis of rheumatoid arthritis. Choice A is incorrect as elevated rheumatoid factor does not specifically indicate spread of the disease to the kidney. Choice C is incorrect as elevated rheumatoid factor does not always represent a decline in the client's condition. Choice D is incorrect as elevated rheumatoid factor is not an indication of the onset of joint degeneration, but rather points towards autoimmune activity.

2. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?

• A. Experiences an elevation in temperature.
• B. Sleeps on the left side.
• C. Cries vigorously.
• D. Eats.

Correct answer: C

Rationale: The correct answer is C: Cries vigorously. When the child cries vigorously, it increases the pressure in the right ventricle, allowing unoxygenated blood to enter the circulating volume, leading to cyanosis. This occurs due to the shunting of blood from the right side of the heart to the left side through the ventricular septal defect. Choices A, B, and D are incorrect because they do not directly impact the pressure in the right ventricle, which is crucial in causing cyanosis in this scenario.

3. What is the priority patient problem for the parents of a newborn born with cleft lip and palate?

• A. Parental role conflict
• B. Risk for delayed growth and development
• C. Risk for impaired attachment
• D. Anticipatory grieving

Correct answer: C

Rationale: The correct answer is C: Risk for impaired attachment. Parents of a newborn with cleft lip and palate may face challenges in bonding with their child due to the physical appearance, impacting attachment. Promoting bonding between parents and the infant is crucial in this situation. Choice A (Parental role conflict) is incorrect as it focuses on conflicting roles rather than the attachment issue. Choice B (Risk for delayed growth and development) is not the priority issue in this scenario as the immediate concern is establishing a healthy attachment. Choice D (Anticipatory grieving) is not the priority patient problem as it pertains more to the emotional response to an anticipated loss, which is not the primary concern at this stage.

4. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

• A. Elevated temperature
• B. Generalized weakness
• C. Diminished lung sounds
• D. Pain when swallowing

Correct answer: D

Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.

5. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. Which response would be the most correct?

• A. The epinephrine given causes nausea and vomiting.
• B. The child is being hydrated with IV fluids.
• C. The child is not hungry.
• D. The child's rapid respirations pose a risk for aspiration.

Correct answer: D

Rationale: The correct answer is D because rapid respirations predispose to aspiration in a child with acute laryngotracheobronchitis. Choice A is incorrect because epinephrine does not directly relate to the need for NPO status. Choice B is incorrect as hydration with IV fluids is not the primary reason for keeping the child NPO. Choice C is incorrect as the child being hungry is not the main concern when keeping a child NPO in this situation.

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