Nursing Elites

1. A 15-month-old child is brought to the clinic for a routine checkup. The nurse notes that the child is not walking independently yet. What should the nurse do next?

• A. Refer the child for a developmental assessment
• B. Encourage the parents to start physical therapy
• C. Reassure the parents that some children walk later than others
• D. Discuss the importance of early intervention services

Correct answer: C

Rationale: The correct answer is to reassure the parents that some children walk later than others. It is essential to understand that children reach developmental milestones at different ages. Walking independently can occur later in some children, and it is normal. Referring the child for a developmental assessment (Choice A) may cause unnecessary concern at this stage. Encouraging physical therapy (Choice B) or discussing early intervention services (Choice D) may not be warranted unless there are specific concerns identified during the checkup.

2. In a hospitalized child receiving IV fluids for dehydration, what is the best indicator that the child’s dehydration is improving?

• A. The child’s urine output increases
• B. The child’s skin turgor is normal
• C. The child’s weight increases
• D. The child’s vital signs are stable

Correct answer: A

Rationale: An increase in urine output is a reliable indicator of improving dehydration in a child. It signifies that the kidneys are functioning better, helping to restore fluid balance in the body. Monitoring urine output is crucial in assessing hydration status and response to treatment. Choices B, C, and D are not the best indicators of improving dehydration. Normal skin turgor is helpful but may not change immediately with improving hydration. Weight increase may reflect retained fluids rather than improved hydration status. Stable vital signs are important but may not always indicate improving dehydration.

3. The healthcare provider is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture?

• A. Metabolic alkalosis.
• B. Respiratory acidosis.
• C. Metabolic acidosis.
• D. Respiratory alkalosis.

Correct answer: A

Rationale: Pyloric stenosis leads to obstruction at the outlet of the stomach, causing frequent vomiting and loss of stomach acids. This results in a loss of hydrochloric acid and hydrogen ions, leading to metabolic alkalosis due to an increase in serum bicarbonate levels. Therefore, the correct answer is metabolic alkalosis. Choice B, respiratory acidosis, is incorrect as it is not typically associated with pyloric stenosis. Choice C, metabolic acidosis, is incorrect because the loss of stomach acids in pyloric stenosis leads to metabolic alkalosis, not acidosis. Choice D, respiratory alkalosis, is also incorrect as it is not the usual consequence of pyloric stenosis.

4. An adolescent’s mother calls the primary HCP’s office to inquire about the results of her daughter’s serum test that was drawn last week. Since it is the teenager’s 18th birthday, how should the nurse respond to this mother’s inquiry?

• A. Ask when the adolescent was last seen in the clinic
• B. Tell the mother to have the teenager call the clinic
• C. Since the serum sample was drawn last week, provide the mother with the findings
• D. Explain that the information cannot be released without the 18-year-old's permission

Correct answer: D

Rationale: When an individual turns 18, they are considered a legal adult and have the right to privacy regarding their medical information. Therefore, the nurse should explain to the mother that without the 18-year-old's permission, the results cannot be disclosed.

5. The healthcare provider is developing the plan of care for a hospitalized child with von Willebrand disease. What priority nursing intervention should be included in this child's plan of care?

• A. Reduce exposure to infection.
• B. Eliminate contact with cold objects.
• C. Guard against bleeding injuries.
• D. Reduce contact with other children.

Correct answer: C

Rationale: Children with von Willebrand disease have a deficiency in a clotting protein, putting them at risk of bleeding episodes. The priority nursing intervention for a child with von Willebrand disease is to guard against bleeding injuries to prevent excessive bleeding or hemorrhage. Choices A, B, and D are not the priority interventions for von Willebrand disease. While reducing exposure to infection is important for any hospitalized child, it is not the priority for von Willebrand disease. Eliminating contact with cold objects is more relevant for conditions like Raynaud's disease. Reducing contact with other children is not a specific priority related to managing von Willebrand disease.

Similar Questions