Nursing Elites

1. How is the diagnosis of Hirschsprung disease confirmed in a 1-month-old infant admitted to the pediatric unit?

• A. Colonoscopy
• B. Rectal biopsy
• C. Multiple saline enemas
• D. Fiberoptic nasoenteric tube

Correct answer: B

Rationale: Rectal biopsy is the definitive diagnostic procedure for Hirschsprung disease in infants. It confirms the absence of ganglion cells in the affected bowel segment, which is characteristic of Hirschsprung disease. Colonoscopy (Choice A) is not typically used for confirmation as it may not provide a definitive result. Multiple saline enemas (Choice C) are utilized in the treatment of meconium ileus, a complication of cystic fibrosis, and not in the diagnosis of Hirschsprung disease. Fiberoptic nasoenteric tube (Choice D) is not a diagnostic tool for Hirschsprung disease; it is commonly used for gastrointestinal decompression or feeding purposes but does not confirm the diagnosis.

2. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. The woman states that her contractions are occurring every 4 to 5 minutes and lasting approximately 30 seconds each. Which of the following questions would be most appropriate to ask at this point?

• A. Has your bag of waters broken yet?
• B. Have you had regular prenatal care?
• C. At how many weeks gestation are you?
• D. How many other children do you have?

Correct answer: C

Rationale: Asking about the gestational age is crucial in determining the stage of labor and assessing potential complications. This information helps in understanding the progress of labor and making appropriate decisions regarding the management of the delivery process. Choices A, B, and D are not as pertinent at this point in providing immediate care or assessing the situation compared to knowing the gestational age.

3. A parent calls the clinic because their child has ingested a small amount of household bleach. What should the nurse advise?

• A. Administer activated charcoal
• B. Induce vomiting immediately
• C. Call the poison control center
• D. Take the child to the emergency department

Correct answer: C

Rationale: In the case of a child ingesting household bleach, the primary advice should be to call the poison control center (Choice C). The poison control center can provide specific guidance on how to manage the ingestion, including whether any immediate interventions are necessary. Administering activated charcoal (Choice A) or inducing vomiting immediately (Choice B) can worsen the situation as they are not recommended treatments for bleach ingestion. Taking the child to the emergency department (Choice D) may be necessary depending on the advice given by the poison control center, but the initial step should be to seek guidance from the experts at the poison control center.

4. After instituting ordered measures to reduce the fever in a 3-year-old with fever and vomiting, what nursing action is most important for the nurse in the emergency department to take?

• A. Preventing shivering
• B. Restricting oral fluids
• C. Measuring output hourly
• D. Taking vital signs hourly

Correct answer: A

Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (Choice B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (Choice C) and taking vital signs hourly (Choice D) are important nursing actions but not as critical as preventing shivering in this scenario. Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.

5. The healthcare provider is assessing the 'resilience' of a 16-year-old boy. Which exemplifies an external protective factor that may help promote resilience in this child?

• A. His ability to take control of his own decisions
• B. His ability to accept his own limitations
• C. His caring relationship with members of his family
• D. His knowledge of when to continue or stop with goal achievement

Correct answer: C

Rationale: A caring relationship with family members is an external protective factor that promotes resilience in individuals, especially in adolescents. This support system provides a sense of security, stability, and emotional connection, which can help the teenager navigate challenges and setbacks. Choices A, B, and D allude to internal factors related to personal decision-making, self-awareness, and goal management, which are important but do not directly represent external protective factors involving external relationships or resources.

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