Nursing Elites

1. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

• A. Unequal leg length
• B. Limited adduction
• C. Diminished femoral pulses
• D. Symmetrical gluteal folds

Correct answer: A

Rationale: In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.

2. A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?

• A. Bulging anterior fontanel
• B. Repeated vomiting
• C. Signs of sleepiness at 10 PM
• D. Inability to read short words from a distance of 18 inches

Correct answer: B

Rationale: Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.

3. A mother has recently been informed that her child has Down syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down syndrome?

• A. Simian crease
• B. Brachycephaly
• C. Oily skin
• D. Hypotonicity

Correct answer: C

Rationale: Individuals with Down syndrome commonly have certain physical characteristics, such as a simian crease (single transverse palmar crease), brachycephaly (shortened front-to-back skull dimension), and hypotonicity (low muscle tone). Oily skin is not a characteristic associated with Down syndrome; instead, individuals with Down syndrome often have dry skin. Therefore, oily skin is the correct answer in this context.

4. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?

• A. Induce vomiting
• B. Hold the next dose of Lithium
• C. Administer an antiemetic
• D. Give the next dose of Lithium

Correct answer: B

Rationale: The correct answer is to hold the next dose of Lithium. The blood lithium value of 1.7 mcg/L exceeds the therapeutic range of 0.5-1.5 mcg/L, indicating potential toxicity. Holding the next dose is crucial to prevent further accumulation of lithium in the bloodstream. Inducing vomiting is not appropriate in this situation as the priority is to prevent further absorption of lithium. Administering an antiemetic is not the priority in lithium toxicity. Giving the next dose of lithium would exacerbate the toxicity and should be avoided.

5. Which of the following is TRUE about shock?

• A. A patient with severe shock does not always have an abnormally low blood pressure.
• B. Confusion and deteriorating mentation are indicative of hypotensive shock.
• C. Patients with compensated shock may not be able to maintain a normal blood pressure.
• D. A normal blood pressure does not imply that the patient is stable.

Correct answer: B

Rationale: Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.

Similar Questions