Nursing Elites

1. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. order an immediate electrocardiogram
• B. count the radial pulse every 1 minute for five times
• C. count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate
• D. have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, an important nursing responsibility is to count the apical pulse for 1 full minute and then compare this rate with the radial pulse rate. This method helps in identifying dysrhythmias as it allows for a direct comparison of the heart's rhythm at two different pulse points. Ordering an immediate electrocardiogram (Choice A) may be necessary but should not be the first step. Counting the radial pulse multiple times (Choice B) is not as accurate as comparing rates directly. Having someone else take the radial pulse simultaneously (Choice D) may introduce errors and inconsistencies in the measurement.

2. What finding would lead the nurse to suspect that a child has Turner syndrome?

• A. Webbed neck
• B. Microcephaly
• C. Gynecomastia
• D. Cognitive delay

Correct answer: A

Rationale: A webbed neck is a key feature seen in Turner syndrome, a genetic condition that occurs in females due to a complete or partial absence of one of the X chromosomes. This physical trait is caused by excess skin on the neck, giving it a webbed appearance. Microcephaly (Choice B) is a condition characterized by a smaller than average head size and is not typically associated with Turner syndrome. Gynecomastia (Choice C) refers to breast enlargement in males and is not a common finding in Turner syndrome, which affects females. Cognitive delay (Choice D) is not a specific characteristic of Turner syndrome, as the syndrome primarily affects physical development and may not necessarily impact cognitive abilities.

3. An instructor is developing a plan for a class of nursing students on various skin disorders. When describing urticaria, what would the instructor include?

• A. It is a type IV hypersensitivity reaction.
• B. Histamine release leads to vasodilation.
• C. Wheals appear first followed by erythema.
• D. The nonpruritic rash blanches with pressure.

Correct answer: B

Rationale: The correct answer is B. Urticaria is a type I hypersensitivity reaction, not type IV. When triggered, histamine release leads to vasodilation, causing characteristic wheals. Wheals are typically followed by erythema. The rash in urticaria is pruritic and does blanch with pressure, unlike the nonpruritic rash described in choice D. Therefore, the most appropriate description of urticaria includes histamine release and vasodilation, as stated in choice B.

4. A parent asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent about rubeola that is different from rubella?

• A. High fever and Koplik spots
• B. Rash on the trunk with pruritus
• C. Nausea, vomiting, and abdominal cramps
• D. Characteristics of a cold, followed by a rash

Correct answer: A

Rationale: The correct answer is A: 'High fever and Koplik spots.' Rubeola (measles) is characterized by a high fever and the presence of Koplik spots, which are not seen in rubella (German measles). Choice B, rash on the trunk with pruritus, is more indicative of rubella. Choice C, nausea, vomiting, and abdominal cramps, are not specific to either rubeola or rubella. Choice D, characteristics of a cold followed by a rash, is not a typical presentation of rubeola or rubella.

5. What foods are appropriate for a 30-month-old toddler on a regular diet?

• A. Hamburger with bun and grapes
• B. Chicken fingers and french fries
• C. Hot dog with bun and potato chips
• D. Macaroni and cheese and Cheerios

Correct answer: D

Rationale: Macaroni and cheese and Cheerios are appropriate choices for a 30-month-old toddler on a regular diet. These foods are easy to chew, digest, and are generally well-liked by toddlers. Option A, a hamburger with bun and grapes, may be difficult for a toddler to handle due to the size of the hamburger and grapes pose a choking hazard. Option B, chicken fingers and french fries, may be too greasy and processed for a toddler's developing digestive system. Option C, hot dog with bun and potato chips, is also not ideal as hot dogs can be a choking hazard and potato chips are high in salt and may not provide adequate nutrition.

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