Nursing Elites

1. A 2-year-old child is admitted to the hospital with a diagnosis of Kawasaki disease. What is the primary goal of therapy during the acute phase?

• A. Preventing coronary artery aneurysms
• B. Reducing fever
• C. Improving cardiac function
• D. Preventing dehydration

Correct answer: A

Rationale: The primary goal of therapy during the acute phase of Kawasaki disease is to prevent coronary artery aneurysms. Kawasaki disease is characterized by systemic vasculitis and the most serious complication is the development of coronary artery aneurysms. While reducing fever and improving cardiac function are important aspects of managing Kawasaki disease, the primary focus in the acute phase is to prevent the development of coronary artery aneurysms. Preventing dehydration is also essential but not the primary goal in managing Kawasaki disease.

2. A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant?

• A. Infection
• B. Dehydration
• C. Urinary retention
• D. Intestinal obstruction

Correct answer: A

Rationale: Infection is the greatest risk for an infant with exstrophy of the bladder due to the exposure of the bladder and surrounding tissues. The bladder mucosa and adjacent tissues being exposed increase the susceptibility to infections. Dehydration (Choice B) is not the primary concern in this condition. Urinary retention (Choice C) is less likely as exstrophy of the bladder usually presents with constant dribbling of urine. Intestinal obstruction (Choice D) is not directly related to exstrophy of the bladder.

3. A child with a diagnosis of acute glomerulonephritis is admitted to the hospital. What is the priority nursing intervention?

• A. Monitoring for hypertension
• B. Providing pain relief
• C. Restricting fluid intake
• D. Encouraging fluid intake

Correct answer: A

Rationale: The correct answer is monitoring for hypertension. Acute glomerulonephritis involves inflammation of the kidney's glomeruli, potentially leading to impaired kidney function and elevated blood pressure. Monitoring for hypertension is crucial as it is a common complication of this condition. Providing pain relief (choice B) may be necessary for comfort but is not the priority. While fluid restriction (choice C) is important in some kidney conditions, in acute glomerulonephritis, maintaining adequate hydration to support kidney function is typically recommended. Encouraging fluid intake (choice D) may exacerbate fluid overload, making it an inappropriate intervention in this scenario.

4. A nurse on the pediatric unit is observing the developmental skills of several 2-year-old children in the playroom. Which child should the nurse continue to evaluate?

• A. Cannot stand on one foot
• B. Builds a tower of 7 blocks
• C. Uses echolalia when speaking
• D. Colors outside the lines of a picture

Correct answer: C

Rationale: The correct answer is C. Using echolalia, which is the repetition of words or phrases, is not typical for a 2-year-old child and may indicate the need for further evaluation. Choices A, B, and D are all within the expected developmental skills for a 2-year-old. While most 2-year-olds may not be able to stand on one foot, it is not a cause for concern at this age. Building a tower of 7 blocks and coloring outside the lines of a picture are both appropriate for a 2-year-old's developmental skills.

5. Based on developmental norms for a 5-year-old child, at what apical pulse did the nurse decide to withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the health care provider?

• A. 60 beats/min
• B. 70 beats/min
• C. 90 beats/min
• D. 100 beats/min

Correct answer: C

Rationale: For a 5-year-old child, an apical pulse below 90 beats/min is a reason to withhold digoxin. Digoxin is a medication commonly used to treat heart conditions, and its administration is based on heart rate parameters. A pulse rate below 90 beats/min indicates bradycardia. In pediatric patients, bradycardia below this threshold may be a sign of toxicity or potential adverse effects of digoxin, necessitating withholding the medication and informing the healthcare provider. Choices A, B, and D are incorrect as they represent pulse rates above the threshold for withholding digoxin in a 5-year-old child.

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