Nursing Elites

1. A 2-year-old child with a diagnosis of autism spectrum disorder is being discharged. What should the nurse include in the discharge teaching?

• A. Maintain a structured routine
• B. Encourage social interaction
• C. Use positive reinforcement
• D. Use a communication board

Correct answer: A

Rationale: The correct answer is to maintain a structured routine. Children with autism spectrum disorder benefit from a structured routine as it provides them with stability and predictability, which can help reduce anxiety and improve behavior management. Encouraging social interaction (Choice B) may not be suitable for all children with autism, as some may struggle with social skills. While positive reinforcement (Choice C) is a helpful strategy, maintaining a structured routine is more essential for overall management in children with autism spectrum disorder. Using a communication board (Choice D) may be beneficial for communication, but establishing a structured routine is a foundational strategy that should be prioritized in the discharge teaching for a child with autism spectrum disorder.

2. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?

• A. Pertussis, tetanus, polio, and measles
• B. Diphtheria, pertussis, tetanus, and polio
• C. Rubella, polio, tuberculosis, and pertussis
• D. Measles, mumps, rubella, and tuberculosis

Correct answer: B

Rationale: By 11 months of age, the recommended vaccines for infants include diphtheria, pertussis, tetanus, and polio. These vaccines are part of the routine immunization schedule to protect infants from serious infectious diseases. Choice A is incorrect because measles is not typically administered at this age. Choice C is incorrect because rubella and tuberculosis are not part of routine infant immunizations. Choice D is incorrect because measles, mumps, and rubella are usually given as a combination vaccine later in childhood, not at 11 months of age.

3. The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching?

• A. I need to avoid pushing or pulling on an arm or leg.
• B. I must avoid lifting the baby from under the armpits.
• C. I should not bend an arm or leg into an awkward position.
• D. We must avoid lifting the legs by the ankles to change diapers.

Correct answer: B

Rationale: Lifting the baby from under the armpits can cause fractures in infants with osteogenesis imperfecta. The correct approach is to support the baby's body and head carefully, avoiding pressure on vulnerable areas prone to fractures. Choices A, C, and D demonstrate proper awareness of caring for an infant with osteogenesis imperfecta by emphasizing caution to prevent fractures.

4. A mother confides to the nurse that she is thinking of divorce. Which suggestion by the nurse would help minimize the effects on the child?

• A. Tell the child together using appropriate terms.
• B. Reassure the child that no one loves him more than his parents.
• C. Engage in special activities with the child to compensate for the divorce.
• D. Keep your feelings to yourself and maintain a positive facade with the child.

Correct answer: A

Rationale: In situations of divorce, it is crucial for both parents to inform the child together using age-appropriate language. This approach helps maintain consistency and clarity for the child, reducing confusion and anxiety. Choice B is incorrect because reassurance should not be solely focused on love but on explaining the situation appropriately. Choice C may inadvertently send the message that the divorce is the child's fault or requires compensation. Choice D is incorrect as children benefit from understanding and processing emotions in a healthy manner, rather than having them kept hidden.

5. Why does a cleft lip predispose an infant to infection?

• A. Waste products accumulate along the defect.
• B. There is evidence of inadequate circulation in the defective area.
• C. Nutrition is inadequate due to ineffective feeding.
• D. Mouth breathing dries the oropharyngeal mucous membranes.

Correct answer: D

Rationale: The correct answer is D. Mouth breathing due to a cleft lip can dry the mucous membranes, making them more susceptible to infection. Choice A is incorrect because waste products do not accumulate along the defect to predispose the infant to infection. Choice B is incorrect as there is no evidence of inadequate circulation being a primary factor in infection predisposition in cleft lip cases. Choice C is incorrect because although ineffective feeding may lead to other issues, it is not the main reason for infection predisposition in infants with a cleft lip.

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