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. When inserting an oropharyngeal airway in a small child, what is the preferred method?

• A. Insert the airway with the curvature towards the roof of the mouth and then rotate it 180 degrees.
• B. Insert the airway as you would in an adult, but use an airway that is one size smaller than usual.
• C. Depress the tongue with a tongue blade and insert the airway with the downward curve facing the tongue.
• D. Open the airway with the tongue-jaw lift maneuver and insert the airway until slight resistance is met.

Correct answer: C

Rationale: When inserting an oropharyngeal airway in a small child, it is crucial to depress the tongue with a tongue blade and insert the airway with the downward curve facing the tongue. This technique helps in maintaining an open airway and preventing obstruction by the tongue. Placing the airway with the curve facing the roof of the mouth or using a smaller size is not recommended for small children, as it may not effectively keep the airway patent. The tongue-jaw lift maneuver is not the preferred method for inserting an oropharyngeal airway in small children.

3. A 6-year-old child is admitted to the hospital with pneumonia. An immediate priority in this child's nursing care would be:

• A. Elimination
• B. Exercise
• C. Nutrition
• D. Rest

Correct answer: D

Rationale: Rest is crucial for recovery in a child with pneumonia as it allows the body to focus its energy on fighting the infection and promoting healing. Adequate rest helps reduce the workload on the lungs, promotes oxygenation, and supports the immune system's response to combat the infection. It is essential to prioritize rest to facilitate a faster recovery and prevent complications in children with pneumonia.

4. Mr. Lopez has a 7-year-old son with growth hormone (GH) deficiency. He shares with the nurse the desire of his son to play ball games. However, his wife feels the child will be in danger since he is smaller than the other children. In planning anticipatory guidance for these parents, the nurse should keep in mind which of the following?

• A. The child should be allowed to play because doing so can foster healthy self-esteem
• B. The risk for fractures is increased because GH deficiency results in fragile bones
• C. Activity could aggravate insulin sensitivity, causing hyperglycemia
• D. Activity would aggravate the child's joints, already overtasked by obesity

Correct answer: A

Rationale: Children with GH deficiency may face challenges due to their size, but it is important to encourage their participation in activities like playing ball games to promote healthy self-esteem. Allowing the child to play can help in building confidence and a sense of accomplishment, which are essential for their overall well-being.

5. The nurse is preparing to administer vitamin K to a newborn. The mother asks why this injection is necessary. What is the nurse's best response?

• A. It helps the baby's liver function properly.
• B. It prevents bleeding disorders in the newborn.
• C. It boosts the baby's immune system.
• D. It promotes the baby's growth and development.

Correct answer: B

Rationale: The correct answer is B. Vitamin K is administered to newborns to prevent bleeding disorders since they have low levels of vitamin K, which is essential for blood clotting. By providing this injection, the nurse ensures that the newborn has an adequate supply of vitamin K to support proper blood clotting and prevent potential bleeding complications. Choices A, C, and D are incorrect because vitamin K's primary role in newborns is related to blood clotting and preventing bleeding, not liver function, immune system, or growth and development.

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