Nursing Elites

1. What explanation should the nurse provide to the parents of a 6-month-old infant diagnosed with cystic fibrosis?

• A. It is a condition affecting the respiratory and digestive systems.
• B. It is an autoimmune disorder affecting multiple organs.
• C. It is a genetic disorder that can be managed with medication.
• D. It is a condition caused by prenatal exposure to toxins.

Correct answer: A

Rationale: The correct answer is A. Cystic fibrosis is a genetic disorder that primarily affects the respiratory and digestive systems. It results in the production of thick, sticky mucus that can clog the lungs and obstruct the pancreas. This explanation is crucial for parents to understand the impact of the condition on their child's health. Choice B is incorrect because cystic fibrosis is not an autoimmune disorder. Choice C is partially correct in that cystic fibrosis is a genetic disorder, but it requires a comprehensive management approach beyond just medication. Choice D is incorrect as cystic fibrosis is not caused by prenatal exposure to toxins but rather by inheriting specific genetic mutations.

2. During an assessment, a nurse is examining the skin of a child with cellulitis. What would the nurse expect to find?

• A. Red, raised hair follicles
• B. Warmth at skin disruption site
• C. Papules progressing to vesicles
• D. Honey-colored exudate

Correct answer: B

Rationale: The correct answer is B: 'Warmth at skin disruption site.' Cellulitis is characterized by localized warmth at the site of skin disruption, which indicates an infection. Choice A, 'Red, raised hair follicles,' is more typical of folliculitis. Choice C, 'Papules progressing to vesicles,' is suggestive of conditions like herpes simplex virus infections. Choice D, 'Honey-colored exudate,' is associated with impetigo, not cellulitis. When assessing cellulitis, nurses should primarily look for warmth, erythema, edema, and tenderness at the affected site.

3. Which is the most appropriate nursing diagnosis for a child with acute glomerulonephritis?

• A. Risk for injury related to malignant process and treatment
• B. Fluid volume deficit related to excessive losses
• C. Fluid volume excess related to decreased plasma filtration
• D. Fluid volume excess related to fluid accumulation in tissues and third spaces

Correct answer: C

Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is 'Fluid volume excess related to decreased plasma filtration.' Acute glomerulonephritis is characterized by inflammation in the glomeruli, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than deficit, making choice C the correct answer. Choice A is incorrect because acute glomerulonephritis is not primarily associated with a malignant process. Choice B is incorrect as the condition typically presents with fluid volume excess rather than deficit. Choice D is also incorrect as fluid accumulation in tissues and third spaces is not a typical manifestation of acute glomerulonephritis.

4. Why should a nurse plan an evening snack for a child receiving Novolin N insulin?

• A. To encourage the child to adhere to the diet.
• B. To provide energy for immediate use.
• C. To help the child gain weight with extra calories.
• D. To counteract late insulin activity with nourishment.

Correct answer: D

Rationale: The correct answer is D. Novolin N insulin peaks in the evening, which can lead to hypoglycemia during the night. Providing an evening snack helps to counteract the late insulin activity and prevent hypoglycemia. Choice A is incorrect because the primary reason for the evening snack is not to encourage adherence to the diet. Choice B is incorrect as the snack is not primarily for immediate energy use. Choice C is incorrect as the goal of the snack is not to help the child gain weight but to manage blood sugar levels.

5. A child with a diagnosis of sickle cell anemia is admitted to the hospital with a vaso-occlusive crisis. What is the most important nursing intervention?

• A. Administering oxygen
• B. Administering pain medication
• C. Monitoring fluid intake
• D. Encouraging physical activity

Correct answer: B

Rationale: During a vaso-occlusive crisis in sickle cell anemia, the priority nursing intervention is administering pain medication to alleviate the severe pain associated with the crisis. While administering oxygen can help improve oxygenation, pain relief is crucial in managing the crisis. Monitoring fluid intake is important in sickle cell anemia but is not the most immediate intervention during a vaso-occlusive crisis. Encouraging physical activity is contraindicated during a vaso-occlusive crisis as it can exacerbate pain and complications.

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