Nursing Elites

1. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?

• A. A history of diarrhea following each feeding
• B. Gastric pain evidenced by vigorous crying
• C. Poor appetite due to a poor sucking reflex
• D. An olive-shaped mass right of the midline

Correct answer: D

Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.

2. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?

• A. Increase intake of high-fiber foods, such as bran cereal
• B. Restrict protein intake by limiting meats and other high-protein foods.
• C. Limit oral fluid intake to 500ml per day
• D. Increase intake of potassium-rich foods such as bananas and cantaloupe.

Correct answer: B

Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.

3. Which individual has the highest risk for developing skin cancer?

• A. A 16-year-old dark-skinned female who tans in tanning beds once a week.
• B. A 65-year-old fair-skinned male who is a construction worker
• C. A 25-year-old dark-skinned male whose mother had skin cancer.
• D. A 70-year-old fair-skinned female who works as a secretary.

Correct answer: B

Rationale: The correct answer is B, a 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals are at higher risk of developing skin cancer due to prolonged sun exposure. Construction workers are often exposed to the sun for long periods, further increasing the risk. Choices A, C, and D are less likely to develop skin cancer compared to choice B due to factors such as age, frequency of tanning bed use, and occupation.

4. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?

• A. Light yellow coloring of the client's skin and eyes.
• B. The client's blood pressure reading of 184/88 mm Hg.
• C. The client vomits 20 ml of clear yellowish fluid.
• D. The IV insertion site is red, swollen, and leaking IV fluid.

Correct answer: B

Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.

5. How are type IV hypersensitivity reactions different from all other types (I, II, or III) of hypersensitivity reactions?

• A. They involve antigen-antibody complexes.
• B. They are mediated by T cells and do not involve antibodies.
• C. They result in immediate allergic reactions.
• D. They are the least severe form of hypersensitivity.

Correct answer: B

Rationale: Type IV hypersensitivity reactions are mediated by T cells and cytokine release, leading to delayed reactions, unlike types I, II, and III, which involve antibodies. Choice A is incorrect because type IV reactions do not involve antigen-antibody complexes. Choice C is incorrect as type IV reactions do not result in immediate allergic reactions. Choice D is incorrect as type IV reactions are not the least severe form of hypersensitivity; in fact, they are known to cause significant tissue damage and inflammation.

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