Nursing Elites

1. The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?

• A. Hypotension
• B. Brown-colored urine
• C. Low urinary specific gravity
• D. Low blood urea nitrogen level

Correct answer: B

Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria resulting in dark, smoky, cola-colored, or brown-colored urine is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

2. A systolic blood pressure of 145 mm Hg is classified as:

• A. Normotensive
• B. Prehypertension
• C. Stage I hypertension
• D. Stage II hypertension

Correct answer: C

Rationale: A systolic blood pressure of 145 mm Hg falls within the range of 140-159 mm Hg, which is classified as Stage I hypertension. Normotensive individuals have a systolic blood pressure less than 120 mm Hg, making choice A incorrect. Prehypertension is characterized by a systolic blood pressure ranging from 120-139 mm Hg, excluding choice B. Stage II hypertension is diagnosed when the systolic blood pressure is greater than 160 mm Hg, making choice D incorrect. Therefore, the correct classification for a systolic blood pressure of 145 mm Hg is Stage I hypertension.

3. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

• A. Watery diarrhea
• B. Ribbon-like stools
• C. Profuse projectile vomiting
• D. Bright red blood and mucus in the stools

Correct answer: D

Rationale: Intussusception is a condition where a part of the bowel slides into the next section, causing an obstruction. The classic presentation includes severe abdominal pain that is crampy, intermittent, and may cause the child to draw knees to the chest. While vomiting can occur, it is not typically projectile in nature. A key hallmark of intussusception is the passage of bright red blood and mucus in the stools, often described as currant jelly-like. Watery diarrhea and ribbon-like stools are not typical signs of intussusception and should not be expected in a child with this condition.

4. Which entry in the medical record best meets the requirement for problem-oriented charting?

• A. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV."?
• B. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."?
• C. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV."?
• D. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"?

Correct answer: B

Rationale: Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The correct answer demonstrates problem-oriented charting by following this structure. Choice A, C, and D do not follow the problem-oriented charting format and instead offer examples of different documentation styles such as PIE charting, focus documentation, and narrative documentation, respectively. Therefore, choice B is the best example of problem-oriented charting among the options provided.

5. Diabetic patients are more prone to ____________ than other people without this chronic disorder.

• A. infection
• B. increased oxygen saturation
• C. low fibrinogen
• D. constipation

Correct answer: A

Rationale: Diabetic patients are more prone to infection than other people without this chronic disorder. Diabetes weakens the immune system and impairs the body's ability to fight off infections, making individuals with diabetes more susceptible to various types of infections. Increased oxygen saturation, low fibrinogen, and constipation are not directly related to diabetes or the increased infection risk associated with the condition. Increased oxygen saturation is actually a positive health indicator, low fibrinogen levels are not a common issue in diabetes, and constipation is not a primary concern when comparing diabetic patients to others without the condition.

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