Nursing Elites

1. At what age may an infant close their eyes to bright lights and show improved head control?

• A. 30-33 weeks after conception
• B. 34-36 weeks after conception
• C. Less than 30 weeks after conception
• D. 37-40 weeks after conception

Correct answer: A

Rationale: Around 30-33 weeks after conception, infants usually start closing their eyes in response to bright lights and exhibit enhanced head control. This developmental milestone indicates progress in their visual and motor abilities, reflecting the maturation of their neurological system. As preterm infants continue to grow and develop, they gradually acquire these skills, showcasing the natural progression of their sensory and motor functions.

2. During an assessment, which manifestation should a healthcare provider expect in an infant with pyloric stenosis?

• A. Bile-stained vomitus
• B. Distended abdomen
• C. Olive-shaped mass in the upper abdomen
• D. Painless, swollen joints

Correct answer: C

Rationale: Pyloric stenosis in infants typically presents with an olive-shaped mass in the upper abdomen due to hypertrophy of the pyloric muscle. This mass can often be palpated during an assessment and is a key characteristic of this condition. Bile-stained vomitus may be seen in conditions such as intestinal obstruction; a distended abdomen can be a nonspecific sign of various conditions, and painless, swollen joints are not typically associated with pyloric stenosis.

3. In the morning, a healthcare professional receives change-of-shift report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the healthcare professional see first?

• A. The child with tachypnea and pulmonary congestion
• B. The child with hepatomegaly and normal respiratory rate
• C. The child with dependent and sacral edema and regular pulse
• D. The child with periorbital edema and normal respiratory rate

Correct answer: A

Rationale: The child with tachypnea and pulmonary congestion should be seen first. Tachypnea indicates an increased respiratory rate, a sign of possible respiratory distress. Pulmonary congestion suggests fluid accumulation in the lungs, posing a serious risk to respiratory function. Immediate attention is crucial in this case. Choice B is incorrect as hepatomegaly alone does not indicate an acute issue requiring immediate attention. Choices C and D, while showing signs of fluid-volume excess, do not present the same level of respiratory compromise as tachypnea and pulmonary congestion, making them lower priority.

4. A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN). Which is the priority nursing diagnosis for this child?

• A. Risk for Injury related to hypertension.
• B. Altered Growth and Development related to chronic disease.
• C. Risk for Infection related to hypertension.
• D. Fluid Volume Excess related to decreased plasma filtration.

Correct answer: A

Rationale: The priority nursing diagnosis for a preschool-age child with acute postinfectious glomerulonephritis (APIGN) is 'Risk for Injury related to hypertension' due to the potential complications such as hypertensive encephalopathy. Hypertension poses an immediate threat to the child's well-being, making it crucial to address the risk for injury associated with elevated blood pressure as the top priority.

5. A patient is receiving glucocorticoids for the treatment of rheumatoid arthritis. The patient complains of having a headache. Which ordered medication should the nurse administer?

• A. Aspirin
• B. Acetaminophen
• C. Ibuprofen
• D. Naproxen Sodium (Aleve)

Correct answer: B

Rationale: When a patient is already receiving glucocorticoids for rheumatoid arthritis and complains of a headache, it is essential to consider the potential interactions and side effects of additional medications. Aspirin and NSAIDs like ibuprofen and naproxen sodium can increase the risk of gastrointestinal irritation and ulceration when used concurrently with glucocorticoids. Acetaminophen is a safer choice in this scenario for managing the patient's headache without exacerbating the gastrointestinal issues associated with the use of glucocorticoids. Acetaminophen does not have the same gastrointestinal side effects as aspirin, ibuprofen, or naproxen sodium, making it the most appropriate option for headache relief in this case.

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