Nursing Elites

1. A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

• A. Place the child in the nearest bed
• B. Administer IV medication to slow down the seizure
• C. Place a padded tongue blade in the child's mouth
• D. Remove the child's toys from the immediate area

Correct answer: D

Rationale: During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action. Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.

2. The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report

• A. Loss of consciousness
• B. Feeding problems
• C. Poor weight gain
• D. Fatigue with crying

Correct answer: A

Rationale: The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.

3. A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?

• A. Is there any history of IV drug use?
• B. Do you use any over-the-counter drugs?
• C. Are you taking corticosteroids for any reason?
• D. Have you recently traveled to a foreign country?

Correct answer: B

Rationale: The most appropriate question for the nurse to ask in this scenario is whether the patient uses any over-the-counter drugs. The patient's symptoms, negative serologic testing for viral hepatitis, and sudden onset of symptoms point towards toxic hepatitis, which can be triggered by commonly used over-the-counter medications like acetaminophen (Tylenol). Asking about IV drug use is relevant for viral hepatitis, not toxic hepatitis. Inquiring about recent travel to a foreign country is more pertinent to potential exposure to infectious agents causing viral hepatitis. Corticosteroid use is not typically associated with the symptoms described in the case.

4. Which of these individuals would the nurse suspect as having the greatest risk of contracting Hepatitis B?

• A. A sexually active 45-year-old man who has Type 1 Diabetes
• B. A 75-year-old woman who lives in a crowded nursing home
• C. A child who lives in a country with poor sanitation and hygiene standards
• D. A sexually active 23-year-old man who works in a hospital

Correct answer: D

Rationale: The correct answer is a sexually active 23-year-old man who works in a hospital. This individual is at the highest risk of contracting Hepatitis B due to exposure in a healthcare setting where potential bloodborne pathogens are present. Being sexually active also increases the risk of transmission through sexual contact. Choice A, a 45-year-old man with Type 1 Diabetes, is not directly associated with an increased risk of Hepatitis B. Choice B, a 75-year-old woman living in a crowded nursing home, is at risk for other infections due to the living environment but not specifically for Hepatitis B. Choice C, a child in a country with poor sanitation, is more at risk for water or foodborne illnesses rather than Hepatitis B transmission.

5. An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?

• A. Does the child have any food allergies?
• B. What do the bowel movements look like?
• C. Has the child eaten any food in the last 24 hours?
• D. Can you describe the type of pain that the child is experiencing?

Correct answer: D

Rationale: The correct answer is asking the parents to describe the type of pain the child is experiencing because a report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. This specific question helps in identifying the key symptom of intussusception. Choices A, B, and C are important aspects of a health history but are not specific to the diagnosis of intussusception. Food allergies, bowel movements, and recent food intake are relevant for a comprehensive assessment but do not directly relate to the specific symptoms of intussusception.

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