Nursing Elites

1. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?

• A. Torticollis, with shortening of the sternocleidomastoid muscle
• B. Craniosynostosis, with premature closure of the cranial sutures
• C. Plagiocephaly, with flattening of one side of the head
• D. Hydrocephalus, with increased head size

Correct answer: A

Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.

2. A nurse is providing discharge instructions for a client who had back surgery. All of the following indicate that the client is ready for discharge EXCEPT:

• A. The client still has sutures at the incision site
• B. The client is able to take a shower
• C. The client must still use an ice pack at the wound site
• D. The client has a temperature of 100.8�F

Correct answer: D

Rationale: When determining if a client is ready for discharge after back surgery, it is essential to ensure that there are no signs of complications or emerging issues. A postoperative temperature of 100.8�F may indicate a developing infection, and the client should not be discharged until this is further evaluated by the physician. Choices A, B, and C are indicators that the client is progressing well and ready for discharge, as having sutures, being able to shower, and using an ice pack are typically expected postoperative activities without indicating a need for further hospitalization.

3. A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result?

• A. Peaked T waves on the ECG
• B. Muscle spasms
• C. Constipation
• D. A prominent U wave on the ECG

Correct answer: A

Rationale: A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability. Muscle spasms (Choice B) are more commonly associated with hypocalcemia. Constipation (Choice C) is not a typical sign of hyperkalemia. A prominent U wave on the ECG (Choice D) is associated with hypokalemia, not hyperkalemia.

4. The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:

• A. To tell the client this is not true; that we all have a purpose in life.
• B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
• C. To reassure the client that you know how the client is feeling and that things will get better.
• D. To identify recent behaviors or accomplishments that demonstrate skill ability.

Correct answer: C

Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.

5. What would a healthcare professional expect to observe while assessing the growth of children during their school-age years?

• A. Decreasing amounts of body fat and muscle mass
• B. Little change in body appearance from year to year
• C. Progressive height increase of 4 inches each year
• D. Yearly weight gain of about 5.5 pounds per year

Correct answer: D

Rationale: During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years. Choice A is incorrect as children at this stage are expected to gain weight and grow in height. Choice B is incorrect as there should be noticeable changes in body appearance due to growth. Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.

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