Nursing Elites

1. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

• A. A cerebral vascular accident
• B. Postoperative meningitis
• C. Medication reaction
• D. Metabolic alkalosis

Correct answer: A

Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.

2. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?

• A. Double the birth weight
• B. Triple the birth weight
• C. Gain 6 ounces each week
• D. Add 2 pounds each month

Correct answer: A

Rationale: Infants typically double their birth weight by 6 months of age as part of normal growth and development. This doubling of weight is a common milestone used by healthcare providers to assess a baby's growth progress. Tripling the birth weight or adding 2 pounds each month would result in excessive weight gain, which is not typical or healthy for an infant. Similarly, gaining 6 ounces each week would also lead to rapid and abnormal weight gain, making it an incorrect choice.

3. When developing a plan of care for a 6-year-old child diagnosed with acute glomerulonephritis, which intervention should the nurse prioritize?

• A. Encourage limited activity and provide safety measures.
• B. Catheterize the child to monitor intake and output strictly.
• C. Encourage the child to talk about feelings related to illness.
• D. Encourage classmates to visit and keep the child informed of school events.

Correct answer: A

Rationale: The priority intervention for a 6-year-old child diagnosed with acute glomerulonephritis should be to encourage limited activity and provide safety measures. In glomerulonephritis, children tend to restrict their activities voluntarily due to fatigue during the active phase of the disease. Catheterization for intake and output monitoring may predispose the child to infection and is not the primary intervention. Encouraging the child to talk about feelings related to the illness may not be developmentally appropriate for a 6-year-old; instead, children can express feelings through play. It is important to limit visitors to allow the child to rest and recover rather than encouraging classmates to visit and keep the child informed of school events.

4. A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:

• A. Hypotriglyceridemia
• B. Abdominal hernia
• C. Anorexia
• D. Peritonitis

Correct answer: A

Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.

5. A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority?

• A. Infection related to hypertension
• B. Injury related to loss of blood in urine
• C. Excessive fluid volume related to decreased plasma filtration
• D. Retarded growth and development related to a chronic disease

Correct answer: C

Rationale: In acute glomerulonephritis, the child experiences excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume is a primary concern due to the disease process. Hypertension and infection are not directly related to acute glomerulonephritis; therefore, they are not the priority client problems. While hematuria (blood in urine) may occur, it typically does not lead to significant injury that takes precedence over excessive fluid volume. Acute glomerulonephritis is an acute condition, not chronic; therefore, retarded growth and development related to a chronic disease is not the priority issue. With proper management, most children recover completely without long-term growth and development issues.

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