Nursing Elites

1. What is an early sign of congestive heart failure that the nurse should recognize?

• A. tachypnea
• B. bradycardia
• C. inability to sweat
• D. increased urinary output

Correct answer: A

Rationale: Tachypnea is an early sign of congestive heart failure that nurses should recognize. Tachypnea refers to rapid breathing, which can be an indication of the body's attempt to compensate for decreased cardiac output in congestive heart failure. Bradycardia (choice B) is a slow heart rate and is not typically associated with congestive heart failure. Inability to sweat (choice C) and increased urinary output (choice D) are not specific early signs of congestive heart failure and are not typically recognized as such.

2. A child has coarctation of the aorta. What does the nurse expect to identify when taking the child’s vital signs?

• A. A weak radial pulse
• B. An irregular heartbeat
• C. A bounding femoral pulse
• D. An elevated radial blood pressure

Correct answer: A

Rationale: When a child has coarctation of the aorta, the nurse would expect to identify a weak radial pulse when taking the child's vital signs. Coarctation of the aorta results in a narrowing of the aorta, leading to reduced blood flow and a weakened pulse. An irregular heartbeat (Choice B) is less likely to be associated with coarctation of the aorta. Similarly, a bounding femoral pulse (Choice C) is not typically observed with this condition. An elevated radial blood pressure (Choice D) is less common as coarctation of the aorta usually causes decreased blood pressure in the lower extremities due to the aortic narrowing.

3. A parent tells the nurse, “My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises.” How should the nurse explain these changes in behavior?

• A. “I will check these responses before deciding how to proceed.”
• B. “Failure of these responses may be related to a developmental delay.”
• C. “Additional sensory stimulation is needed to aid in the return of these responses.”
• D. “These responses are replaced by voluntary activity at about five months of age.”

Correct answer: D

Rationale: The correct answer is D. The grasp reflex and startle reflex (Moro reflex) are normal in newborns but typically disappear as the infant's nervous system matures and voluntary control develops. At around five months of age, these reflexes are replaced by voluntary movements as part of the normal developmental process. Choices A, B, and C are incorrect. Choice A suggests delaying a decision until further assessment, which is not necessary as the disappearance of these reflexes is a normal part of infant development. Choice B implies a developmental delay, which is not the case as these reflexes naturally disappear with age. Choice C recommending additional sensory stimulation is unnecessary and not the reason for the absence of these reflexes.

4. What intervention best meets a major developmental need of a newborn in the immediate postoperative period?

• A. Giving a pacifier to the newborn
• B. Putting a mobile over the newborn’s crib
• C. Providing the newborn with a soft, cuddly toy
• D. Warming the newborn’s formula before feeding

Correct answer: A

Rationale: The correct answer is giving a pacifier to the newborn. Sucking is a natural reflex and a source of comfort for newborns, especially postoperatively. A pacifier can help meet their developmental needs by providing soothing comfort. Choices B, C, and D do not directly address the major developmental need related to the newborn's comfort and reflexes postoperatively. Putting a mobile over the crib, providing a cuddly toy, or warming formula, although potentially beneficial in other contexts, do not specifically target the developmental need of sucking for comfort. Offering a pacifier is a safe and effective way to address this developmental need in newborns.

5. A parent receives a note from the school that a student in class has head lice. The parent calls the school nurse to ask how to check for head lice. What instructions should the nurse provide?

• A. Ask the child where it itches.
• B. Check to see if your dog has ear mites.
• C. Look along the scalp line for white dots.
• D. Observe between the fingers for red lines.

Correct answer: C

Rationale: The correct answer is to look along the scalp line for white dots (nits) when checking for head lice. White dots/nits are the eggs of head lice and are commonly found attached to the hair shaft near the scalp. This method helps identify if head lice are present. Choice A is incorrect as itching alone may not be a definitive sign of head lice; it could be due to other reasons. Choice B is irrelevant as ear mites in dogs are not related to head lice infestation in humans. Choice D is also incorrect as observing between the fingers for red lines is not a method for checking head lice.

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