Nursing Elites

1. A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 to 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?

• A. Bilateral bronchial breath sounds.
• B. Diaphragmatic respiration.
• C. A resting respiratory rate of 35 breaths per minute.
• D. Flaring of the nares.

Correct answer: D

Rationale: Flaring of the nares is a clinical sign of acute respiratory distress in infants. It indicates an increased effort to breathe and is a crucial finding that requires immediate attention, as it signifies the child is having difficulty breathing and may be in respiratory distress. Choices A, B, and C are incorrect. Bilateral bronchial breath sounds may be present in conditions like pneumonia but do not specifically indicate acute respiratory distress. Diaphragmatic respiration is a normal breathing pattern and not a sign of distress. A resting respiratory rate of 35 breaths per minute in a 4-month-old infant is within the expected range, so it does not necessarily indicate acute respiratory distress.

2. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

• A. The mother is a single parent and lives with her parents
• B. The mother states the baby is irritable during feedings
• C. The infant’s formula has been changed twice
• D. The diaper area shows severe skin breakdown

Correct answer: D

Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.

3. Which nursing diagnosis is a priority for a 4-year-old child diagnosed with nephrotic syndrome?

• A. Impaired urinary elimination.
• B. Risk for infection.
• C. Fluid volume excess.
• D. Risk for impaired skin integrity.

Correct answer: C

Rationale: In a child with nephrotic syndrome, fluid volume excess is a priority nursing diagnosis due to the risk of edema and related complications. This patient may experience significant fluid retention, leading to edema, hypertension, and potential respiratory distress. Monitoring and managing fluid volume excess are crucial in preventing further complications and supporting the child's health during nephrotic syndrome. The other options are not the priority in this case. Impaired urinary elimination is not typically a primary concern in nephrotic syndrome. While infection is a risk due to compromised immunity, fluid volume excess poses a more immediate threat to the child's health. Risk for impaired skin integrity may be a concern secondary to edema, but addressing fluid volume excess takes precedence.

4. During a routine physical exam, a male adolescent client tells the nurse, 'sometimes, my mother gets angry because I want to be with my own friends.' What is the best initial response by the nurse?

• A. Offer reassurance that his mother's concern is normal
• B. Determine if his friends are engaged in unsafe behaviors
• C. Ask about the client's response to his mother's anger
• D. Offer to discuss his concerns with his mother

Correct answer: C

Rationale: When a client expresses concerns about family dynamics, it is important to explore their feelings and reactions to the situation. By asking about the client's response to his mother's anger, the nurse can gain insight into the client's emotions, thoughts, and coping mechanisms. Understanding these aspects is crucial in providing appropriate support and guidance. Option A is incorrect because it focuses solely on reassuring the client about his mother's concern without addressing the client's feelings. Option B assumes negative behaviors without evidence. Option D jumps to discussing concerns with the mother without understanding the client's perspective first.

5. A 13-year-old client with type 1 diabetes presents to the clinic with a blood glucose level of 400 mg/dL. The client reports feeling thirsty and having frequent urination. What is the nurse’s priority action?

• A. Administer insulin as prescribed
• B. Encourage the client to drink water
• C. Check the client’s urine for ketones
• D. Reinforce the importance of diet and exercise

Correct answer: A

Rationale: In a client with type 1 diabetes presenting with hyperglycemia (blood glucose level of 400 mg/dL) and symptoms of thirst and frequent urination, the priority action for the nurse is to administer insulin as prescribed. Insulin helps lower the blood glucose level and prevents complications like diabetic ketoacidosis. While encouraging hydration is essential, administering insulin is crucial to address the high blood glucose levels. Checking urine for ketones is important in diabetic management but is secondary to administering insulin in this scenario. Reinforcing diet and exercise importance is vital for diabetes management but not the priority in acute hyperglycemia.

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