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. What explanation should be given to a parent about the purpose of a tetanus toxoid injection for their child?

• A. Passive immunity is conferred for life.
• B. Long-lasting active immunity is conferred.
• C. Lifelong active natural immunity is conferred.
• D. Passive natural immunity is conferred temporarily.

Correct answer: B

Rationale: The correct answer is B: 'Long-lasting active immunity is conferred.' Tetanus toxoid injection provides long-lasting active immunity by stimulating the body to produce its own antibodies. Choice A is incorrect because tetanus toxoid injection does not provide passive immunity. Choice C is incorrect because the immunity conferred by the vaccine is not natural but artificially induced. Choice D is incorrect as the immunity provided by the tetanus toxoid injection is active, not passive.

3. What should the nurse suggest to a parent asking for advice on managing their child's earache and fever?

• A. Applying a warm compress to the affected ear
• B. Giving the child a cold drink
• C. Administering acetaminophen
• D. Taking the child to the emergency department

Correct answer: A

Rationale: The correct answer is to suggest applying a warm compress to the affected ear. This can help alleviate pain and discomfort associated with the earache. Giving a cold drink (Choice B) may not address the underlying issue and is not a recommended treatment for earaches. Administering acetaminophen (Choice C) can help reduce fever but may not directly target the earache. Taking the child to the emergency department (Choice D) is usually not necessary for a common earache unless there are severe symptoms or complications present.

4. Which cardiac defects are associated with tetralogy of Fallot?

• A. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve stenosis
• B. Origin of the aorta from the right ventricle and of the pulmonary artery from the left ventricle
• C. Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
• D. Altered connection between the pulmonary artery and the aorta, right ventricular hypertrophy, and an atrial septal defect

Correct answer: C

Rationale: Tetralogy of Fallot is characterized by a combination of four specific cardiac defects: right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta. Choice A is incorrect as it includes mitral valve stenosis, which is not typically part of tetralogy of Fallot. Choice B describes transposition of the great arteries rather than tetralogy of Fallot. Choice D includes an atrial septal defect, which is not part of the classic presentation of tetralogy of Fallot.

5. 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.

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