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 is the main function of the uterus?

• A. Dilate and expel the baby from the cervix.
• B. House the fetus as it grows for 40 weeks.
• C. Provide a cushion and protect the fetus from infection.
• D. Provide oxygen and other nutrients to the fetus.

Correct answer: B

Rationale: The main function of the uterus is to house and nurture the growing fetus for approximately 40 weeks during pregnancy. It provides the necessary environment for the fetus to develop and grow until it is ready for birth. Choice A is incorrect as the cervix, not the uterus, dilates during labor to allow the baby to pass through. Choice C is incorrect as while the uterus does provide a protective environment, its primary function is not to act as a cushion. Choice D is incorrect as the placenta, not the uterus, is responsible for providing oxygen and nutrients to the fetus.

3. When working with a new adolescent patient, which greeting by the nurse indicates awareness of the needs of the adolescent client?

• A. I will talk with your parents first, and then you can tell me why you are here.
• B. Please let me know what your concerns are, and if you have any questions.
• C. Before we begin, I will need to know if you are sexually active.
• D. I will do the physical exam first, and then we will talk about your history.

Correct answer: B

Rationale: The greeting 'Please let me know what your concerns are, and if you have any questions.' indicates awareness of the needs of the adolescent client. It encourages open communication, allows the adolescent to voice their concerns, and shows that their questions are welcomed and valued, fostering a trusting nurse-patient relationship. Choices A, C, and D do not prioritize the adolescent's perspective or promote open communication. Asking to talk to the parents first (Choice A) may hinder the adolescent's autonomy and trust. Inquiring about sexual activity (Choice C) may be necessary but should be approached with sensitivity and privacy. Doing the physical exam first (Choice D) before discussing the patient's history may not align with the adolescent's need for communication and understanding.

4. A mother of a 6-year-old actively playing child, diagnosed with type 1 diabetes mellitus a year ago, calls a clinic nurse and reports that the child has been sick. She checked the child's urine, which was positive for ketones. What should the nurse instruct the mother to do?

• A. Administer an additional dose of regular insulin
• B. Come to the clinic immediately
• C. Encourage the child to drink liquids
• D. Hold the next dose of insulin

Correct answer: C

Rationale: Encouraging the child to drink liquids is essential in managing ketones in urine. Increased fluid intake can help prevent dehydration and aid in flushing out ketones, which is crucial in managing diabetic ketoacidosis, a serious complication of uncontrolled diabetes.

5. Where is the most appropriate location to perform a procedure on a preschooler?

• A. Perform the procedure in the child's hospital bed.
• B. Perform the procedure in the treatment room.
• C. Allow the child to decide when the procedure will be performed.
• D. Ask the parents to help restrain the child so the procedure can be performed.

Correct answer: B

Rationale: When performing a procedure on a preschooler, it is most appropriate to do so in the treatment room. This setting is specifically designed to provide a suitable environment with necessary equipment and resources to ensure the procedure is carried out safely and efficiently. It helps minimize distractions and provides a controlled environment for healthcare providers to focus on the child's needs. Choices A, C, and D are incorrect because performing the procedure in the child's hospital bed may lack the necessary resources and equipment, allowing the child to decide when the procedure will be performed may not be feasible due to medical necessity and urgency, and asking parents to help restrain the child is not ideal as it may not provide a professional and controlled setting for the procedure.

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