Nursing Elites

1. A 14-month-old child is admitted to the hospital with laryngotracheobronchitis (LTB). Which assessment findings should the nurse expect?

• A. Cyanosis and dyspnea
• B. Productive cough and high fever
• C. Barking cough and inspiratory stridor
• D. Pale laryngeal and dyspnea

Correct answer: C

Rationale: The correct answer is C: 'Barking cough and inspiratory stridor.' Classic signs of laryngotracheobronchitis (LTB) include a barking cough, often described as a seal-like cough, and inspiratory stridor, which is a high-pitched sound heard during inspiration. These symptoms occur due to inflammation and narrowing of the upper airway. Choices A, B, and D are incorrect as they do not align with the typical assessment findings of LTB. Cyanosis and dyspnea (Choice A) may occur in severe cases but are not specific to LTB. Productive cough and high fever (Choice B) are more indicative of lower respiratory tract infections. Pale laryngeal and dyspnea (Choice D) are not characteristic findings of LTB.

2. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

• A. Ask the parent when the neck was injured
• B. Refer for immediate medical evaluation
• C. Continue assessment to determine the cause of the neck pain
• D. Record head lag on the assessment record and continue the assessment of the child

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

3. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?

• A. Inspect the chest
• B. Auscultate the heart
• C. Palpate the apical pulse
• D. Palpate the nail bed with pressure to produce a slight blanching

Correct answer: D

Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.

4. The nurse is caring for a child after a cleft palate repair who is on a clear liquid diet. Which feeding device should the nurse use to deliver the clear liquid diet?

• A. Straw
• B. Spoon
• C. Sippy cup
• D. Open cup

Correct answer: D

Rationale: An open cup is recommended for feeding after cleft palate repair to prevent injury to the surgical site and avoid creating negative pressure, which could disrupt the repair.

5. The clinic nurse is instructing parents about caring for a toddler with ascariasis (common roundworm). Which statement made by the parents indicates a need for further teaching?

• A. We will wash our hands often, especially after diaper changes
• B. We know that roundworm can be transmitted from person to person
• C. We will be sure to continue the nitazoxanide (Alinia) orally for 3 days
• D. We will bring a stool sample to the clinic for examination in 2 weeks

Correct answer: B

Rationale: Roundworm (ascariasis) is typically transmitted through ingestion of contaminated soil, not directly from person to person. This statement indicates a misunderstanding requiring clarification.

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