Nursing Elites

1. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

• A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
• B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
• C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
• D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.

Correct answer: C

Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.

2. A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?

• A. Why don't you switch to formula to ensure your baby is eating enough?
• B. It is common for new mothers to worry that they are not producing enough milk for their baby.
• C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
• D. Your newborn will need to remain in the hospital so his weight can be monitored.

Correct answer: C

Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.

3. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute anti-parkinsonian drugs.

Correct answer: A

Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.

4. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

• A. Heart rate
• B. Pedal pulses
• C. Lung sounds
• D. Pupil responses

Correct answer: D

Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.

5. The nurse is providing care for a client with a new tracheostomy. Which of these assessments is a priority?

• A. Checking the client's oxygen saturation level
• B. Monitoring the client's pain level
• C. Checking the tracheostomy site for signs of infection
• D. Monitoring the client's level of consciousness

Correct answer: C

Rationale: When caring for a client with a new tracheostomy, the priority assessment is checking the tracheostomy site for signs of infection. This is essential to detect early signs of complications such as infection, which can lead to serious issues. Monitoring oxygen saturation is important but not as critical as ensuring the tracheostomy site is free from infection. Pain assessment and level of consciousness are also important but secondary to assessing for signs of infection in this scenario.

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