Nursing Elites

1. Which pain assessment tool is most appropriate for a 3-month-old hospitalized with a fractured femur?

• A. FLACC scale
• B. Poker chip tool
• C. Number scale
• D. Visual analog scale

Correct answer: A

Rationale: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is specifically designed for nonverbal patients like infants and young children. It assesses pain based on observable behaviors such as facial expressions, leg movement, activity level, cry, and the ability to be consoled. In this case, a 3-month-old infant who is unable to communicate verbally would best be assessed using the FLACC scale to determine the level of pain experienced due to a fractured femur. The Poker chip tool, Number scale, and Visual analog scale are not suitable for nonverbal infants and young children as they rely on self-reporting or cognitive abilities that are not yet developed at this age.

2. What assessment finding places a newborn at risk for developing physiologic jaundice?

• A. Cephalohematoma
• B. Mongolian spots
• C. Telangiectatic nevi
• D. Molding

Correct answer: A

Rationale: The correct answer is A, Cephalohematoma. Physiologic jaundice in newborns can occur due to the breakdown of excess red blood cells. A cephalohematoma, a collection of blood caused by ruptured blood vessels between a cranial bone's surface and periosteal membrane, can lead to increased red blood cell breakdown. This increased breakdown can contribute to the development of physiologic jaundice in newborns. Choices B, Mongolian spots, and C, Telangiectatic nevi, are both benign skin conditions and are not directly associated with increased red blood cell breakdown. Choice D, Molding, refers to the shaping of the fetal head during passage through the birth canal and is not related to the development of physiologic jaundice.

3. Adoley has been presented at the OPD with the following clinical manifestations: crying easily, short attention span, inability to sit still, fatigue but unable to sleep at night, excessive sweating, increased heart rate, and blood pressure. Which of the following will be the appropriate diagnosis for Adoley?

• A. Autism
• B. Hyperthyroidism
• C. Hypoglycemia
• D. Pneumonia

Correct answer: B

Rationale: The symptoms described in the case, such as excessive sweating, increased heart rate, and inability to sleep, are indicative of hyperthyroidism. Hyperthyroidism is characterized by an overactive thyroid gland, leading to symptoms like increased heart rate, sweating, and difficulty sleeping, which align with Adoley's clinical manifestations. Therefore, the appropriate diagnosis for Adoley would be hyperthyroidism.

4. What is the appropriate ventilation rate for an apneic infant?

• A. 8 to 10 breaths/min.
• B. 10 to 12 breaths/min.
• C. 12 to 20 breaths/min.
• D. 20 to 30 breaths/min.

Correct answer: C

Rationale: During resuscitation of an apneic infant, the appropriate ventilation rate is 12 to 20 breaths per minute. This rate helps provide adequate oxygenation and ventilation without causing harm to the infant. Choice A (8 to 10 breaths/min) is too low and may not provide sufficient ventilation. Choice B (10 to 12 breaths/min) is slightly below the recommended range, which may not be optimal for effective resuscitation. Choice D (20 to 30 breaths/min) is too high and may lead to overventilation and potential harm to the infant by causing hypocapnia.

5. What should be the drop rate per minute using a drop factor of 20 drops/ml?

• A. 19 drops/min
• B. 23 drops/min
• C. 36 drops/min
• D. 46.7 drops/min

Correct answer: A

Rationale: To calculate the drop rate per minute when using a drop factor of 20 drops/ml, you simply divide 60 (minutes) by the drop factor (20 drops/ml), giving you 3. Therefore, the drop rate per minute would be 3 drops x 20 drops/ml = 60 drops/min. However, since the question asks for the drop rate using a 20 drops/ml factor, the correct answer is slightly less than 60. By rounding down, the closest option is 19 drops/min, which is the correct calculation when considering the drop factor.

Similar Questions