Nursing Elites

1. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?

• A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
• B. Risk for altered gas exchange.
• C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
• D. Risk for increased cardiac output, related to the use of antihypertensive drugs.

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.

2. Matt is a 36-year-old male. In the past year, he has noticed that his limbs sometimes move on their own, and he has also started having trouble remembering things and doing simple calculations. Matt’s father and grandfather were also known to have similar problems during their adulthood. Matt is most likely suffering from:

• A. Phenylketonuria (PKU).
• B. Cystic fibrosis.
• C. Turner syndrome.
• D. Huntington’s disease (HD).

Correct answer: D

Rationale: Matt is exhibiting symptoms typical of Huntington’s disease (HD), a hereditary condition characterized by involuntary movements, cognitive impairment, and behavioral changes. The fact that Matt's father and grandfather had similar issues supports the genetic nature of the disease. Phenylketonuria (PKU) is a metabolic disorder that affects amino acid metabolism, not presenting with the symptoms described. Cystic fibrosis primarily affects the respiratory and digestive systems, not causing the neurological symptoms described. Turner syndrome is a genetic condition affecting females and is not associated with the symptoms described in the case of Matt.

3. What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

• A. Assessing the strength of uterine contractions
• B. Re-evaluating the need for medication
• C. Reminding her to push 3 times with each contraction
• D. Assisting her to maintain control

Correct answer: D

Rationale: During the transitional phase of labor, which is the most intense phase, the primary focus of nursing care for a client who anticipates an unmedicated delivery should be assisting her to maintain control. This is essential to help her manage the intense pain and anxiety associated with this phase without the use of medication. Assessing the strength of uterine contractions (Choice A) is important but not the primary focus during the transitional phase. Re-evaluating the need for medication (Choice B) is not applicable as the client anticipates an unmedicated delivery. Reminding her to push 3 times with each contraction (Choice C) is more related to the pushing stage of labor and not the transitional phase.

4. During which of the following periods does the development of arms and legs occur in a pregnancy?

• A. Development of the lungs
• B. Development of the heart
• C. Development of arms and legs
• D. Development of the stomach

Correct answer: C

Rationale: The correct answer is C. The development of arms and legs occurs during the critical period of the fourth to eighth weeks of pregnancy. This timeframe is crucial for the formation of limbs and other key body parts. Choices A, B, and D are incorrect because the development of the lungs, heart, and stomach respectively occurs at different stages of fetal development and is not primarily associated with the fourth to eighth weeks of pregnancy.

5. Are babies with fetal alcohol syndrome (FAS) often larger than normal, and so are their brains?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: B

Rationale: The correct answer is B: FALSE. Babies with fetal alcohol syndrome (FAS) are typically smaller than normal, with smaller brains and developmental issues. Choice A is incorrect because babies with FAS are not larger than normal. Choice C is incorrect as it does not accurately reflect the typical characteristics of babies with FAS. Choice D is incorrect as babies with FAS are not always larger than normal.

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