Nursing Elites

1. A 5-year-old is hospitalized with a fractured femur. Which pain assessment tool is appropriate for this child?

• A. CRIES Scale
• B. Faces Pain Rating Scale
• C. SUN Scale
• D. NIPS Scale

Correct answer: B

Rationale: The Faces Pain Rating Scale is appropriate for assessing pain in children who can express their feelings visually. For a 5-year-old child who can communicate effectively, using a tool like the Faces Pain Rating Scale, which uses facial expressions to indicate pain levels, is more suitable than the CRIES Scale (used for neonates), the SUN Scale (used for infants), or the NIPS Scale (used for preterm and term newborns).

2. What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?

• A. Closed anterior fontanel
• B. Sunken anterior fontanel
• C. Bulging anterior fontanel
• D. Pulsating anterior fontanel

Correct answer: D

Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.

3. Which are included in the evaluation step of the nursing process? (Select all that apply.)

• A. All below
• B. Ascertaining if the plan requires modification
• C. Determination if the outcome has been met
• D. Selecting alternative interventions if the outcome has not been met

Correct answer: A

Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.

4. What signs and symptoms are indicative of a urinary tract disorder in the infancy period (1-24 months)? (Select all that apply.)

• A. All below
• B. Poor feeding
• C. Hypothermia
• D. Frequent urination

Correct answer: A

Rationale: In infants, urinary tract disorders may present with poor feeding, hypothermia, and frequent urination. Pallor can be associated with other conditions but is less specific to urinary tract disorders.

5. An infant requires surgery for repair of a cleft lip. An important priority of the preoperative nursing care is which?

• A. Initiating discharge teaching
• B. Performing baseline physical and behavioral assessment
• C. Observing for allergic reactions to preoperative antibiotics
• D. Determining whether this defect exists in other family members

Correct answer: B

Rationale: Performing a baseline physical and behavioral assessment is crucial to determine the infant's current health status and to identify any potential risks before surgery.

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