Nursing Elites

1. When assessing a 30-year-old female who was sexually assaulted, what is the MOST important action for you to take?

• A. Have a female healthcare provider perform the assessment.
• B. Advise against showering or changing clothes.
• C. Acknowledge that the patient is a potential crime scene.
• D. Ensure that all life-threatening injuries are treated.

Correct answer: D

Rationale: In cases of sexual assault, the priority is to address any life-threatening injuries first before proceeding with other aspects of care. Although preserving evidence and approaching the situation with sensitivity are crucial, immediate treatment of life-threatening conditions takes precedence to ensure the patient's well-being and safety. Having a female healthcare provider, advising against showering or changing clothes, and acknowledging the patient as a potential crime scene are important but secondary considerations compared to addressing any life-threatening injuries promptly.

2. Which of the following findings is abnormal?

• A. Rapid, irregular breathing in a newly born infant
• B. Heart rate of 80 beats/min in a 3-month-old infant
• C. Respiratory rate of 26 breaths/min in a 2-year-old child
• D. Systolic BP of 100 mm Hg in a 10-year-old child

Correct answer: B

Rationale: A heart rate of 80 beats per minute in a 3-month-old infant is abnormally low for that age group and could indicate underlying health issues. The normal heart rate for a 3-month-old infant is typically higher, around 100-150 beats per minute. Therefore, this finding stands out as abnormal and warrants further evaluation. Choice A is not necessarily abnormal in a newly born infant as irregular breathing patterns can be common during the neonatal period. Choice C falls within the normal respiratory rate range for a 2-year-old child, which is around 20-30 breaths per minute. Choice D reflects a systolic blood pressure value within the normal range for a 10-year-old child, which is typically around 90-110 mm Hg.

3. In counseling the parents of a child with hypopituitarism, Nurse Gyimah is asked about their child's condition. Which of the following phrases, if stated by the nurse, best describes the condition?

• A. Linear growth retardation with skeletal proportions normal for chronologic age
• B. A complete normal growth pattern, but with the onset of precocious puberty
• C. Normal growth for the first five years, followed by progressive linear growth retardation
• D. Growth retardation in which height and weight are equally affected

Correct answer: A

Rationale: Hypopituitarism is characterized by linear growth retardation with skeletal proportions normal for chronologic age. This means that although the child experiences growth retardation, their skeletal proportions are appropriate for their age, which distinguishes it from other conditions like precocious puberty or equal height and weight affectation. Choice B is incorrect as hypopituitarism does not involve precocious puberty. Choice C is wrong as it describes a different growth pattern not typical of hypopituitarism. Choice D is also incorrect as in hypopituitarism, height and weight are not equally affected, rather the focus is on linear growth retardation with normal skeletal proportions.

4. A postpartum client who delivered a healthy newborn is being assessed by a nurse. Which finding would indicate a complication during the early postpartum period?

• A. Moderate lochia rubra
• B. Bradycardia
• C. Elevated blood pressure
• D. Uterine contraction

Correct answer: C

Rationale: An elevated blood pressure in the postpartum period may indicate the onset of preeclampsia, a serious complication that requires immediate medical attention. Preeclampsia is characterized by high blood pressure, protein in the urine, and sometimes swelling in the hands and face. If left untreated, preeclampsia can lead to serious complications for both the mother and the baby. Therefore, it is crucial for healthcare providers to closely monitor blood pressure levels in postpartum clients to promptly address any signs of preeclampsia. Choices A, B, and D are not indicative of a complication during the early postpartum period. Moderate lochia rubra is a normal finding as it indicates the normal discharge of blood and tissue from the uterus after childbirth. Bradycardia, a slow heart rate, is not typically a concern in the absence of other symptoms or signs of distress. Uterine contractions are essential for involution and are expected in the postpartum period.

5. In the Integrated Management of Neonatal and Childhood Illnesses, one of the things to look for is danger signs. Which of the following will you consider a danger sign in a child?

• A. The child vomits everything
• B. A child with diarrhea
• C. A child with headache
• D. All of the above

Correct answer: A

Rationale: The correct answer is A: 'The child vomits everything.' Vomiting everything is considered a danger sign in a child as it can lead to dehydration and other serious complications. Recognizing this sign early can help in timely intervention and management of the child's condition. Choices B and C are incorrect as diarrhea and headache, while concerning, are not specific danger signs highlighted in the Integrated Management of Neonatal and Childhood Illnesses.

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