Nursing Elites

1. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?

• A. Polyuria
• B. Weight gain
• C. Hypotension
• D. Grossly bloody urine

Correct answer: B

Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.

2. A healthcare professional is reviewing a patient's chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?

• A. Borrelia burgdorferi
• B. Streptococcus pyogenes
• C. Bacillus anthracis
• D. Enterococcus faecalis

Correct answer: A

Rationale: Lyme disease, the most common vector-borne disease in the United States, is caused by the bacterium Borrelia burgdorferi. Borrelia burgdorferi is transmitted to humans through the bite of infected black-legged ticks. Streptococcus pyogenes is associated with strep throat and other infections, not Lyme disease. Bacillus anthracis causes anthrax, a separate infectious disease. Enterococcus faecalis is more commonly linked to urinary tract infections and other healthcare-associated infections, not Lyme disease.

3. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?

• A. Oculogyric crisis
• B. Tardive dyskinesia
• C. Nystagmus
• D. Dysphagia

Correct answer: A

Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.

4. The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report

• A. Loss of consciousness
• B. Feeding problems
• C. Poor weight gain
• D. Fatigue with crying

Correct answer: A

Rationale: The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.

5. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:

• A. Increase fluids that are high in protein
• B. Restrict fluids
• C. Force fluids and reassess blood pressure
• D. Limit fluids to non-caffeine beverages

Correct answer: D

Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.

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