Nursing Elites

1. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

• A. Permanent lifestyle changes need to be made to promote safety in the home
• B. The chorea or movements are temporary and will eventually disappear
• C. Muscle tension is decreased with fine motor project skills, so these activities should be encouraged
• D. Consistent discipline is needed to help the child control the movements

Correct answer: C

Rationale: Chorea associated with rheumatic fever is usually temporary and will subside over time.

2. A 3-year-old with a congenital heart defect has had a steady decrease in heart rate, now at 76 bpm from 110 bpm four hours ago. Which additional finding should be reported immediately to a healthcare provider?

• A. Oxygen saturation of 94%.
• B. Respiratory rate of 25 breaths/minute.
• C. Urine output of 20 mL/hr.
• D. Blood pressure of 70/40.

Correct answer: D

Rationale: A significant drop in heart rate and blood pressure should be reported immediately as it may indicate worsening of the congenital heart defect. The blood pressure of 70/40 is dangerously low and requires immediate attention to prevent further complications. Oxygen saturation of 94% is within an acceptable range and does not indicate immediate danger. A respiratory rate of 25 breaths/minute is slightly elevated but not a critical finding. Urine output of 20 mL/hr is low but may not be the most concerning finding in this scenario compared to the drop in blood pressure.

3. A 3-year-old child is admitted to the hospital with a diagnosis of pneumonia. The nurse notes that the child has a fever and is breathing rapidly. What is the nurse’s priority action?

• A. Administer antipyretic medication
• B. Obtain a chest X-ray
• C. Start the child on oxygen therapy
• D. Notify the healthcare provider

Correct answer: C

Rationale: In a child with pneumonia who is breathing rapidly, the priority action for the nurse is to start the child on oxygen therapy. This intervention is essential to ensure adequate oxygenation, which is crucial in managing respiratory distress and preventing complications associated with hypoxia. Administering antipyretic medication (Choice A) may help reduce the fever but does not address the immediate need for oxygen therapy. Obtaining a chest X-ray (Choice B) is important for diagnosis but providing oxygen is more urgent. Notifying the healthcare provider (Choice D) can be done after initiating oxygen therapy to update on the patient's condition.

4. The nurse is preparing to administer an immunization to a 5-year-old child. The parent asks if the vaccine can be given in a different way because the child is afraid of needles. What is the nurse’s best response?

• A. We can apply a numbing cream before the injection
• B. There is no other way to administer this vaccine
• C. We can give the vaccine as a nasal spray
• D. We can skip the vaccine if the child is too afraid

Correct answer: C

Rationale: Administering the vaccine as a nasal spray provides an alternative method of delivery that avoids the use of needles, addressing the child's fear while ensuring immunization. Nasal sprays are effective for certain vaccines and can be a suitable option in this scenario. Choice A is not the best response as it only addresses pain management but does not eliminate the use of needles. Choice B is incorrect as there are alternative delivery methods like nasal sprays. Choice D is incorrect as skipping the vaccine would leave the child unprotected and is not a recommended course of action.

5. The healthcare provider is caring for a 6-year-old child diagnosed with glomerulonephritis. Which finding should the healthcare provider report promptly to the healthcare provider?

• A. Dark-colored urine
• B. Mild periorbital edema
• C. Blood pressure of 150/95 mm Hg
• D. Urine output of 250 mL in 24 hours

Correct answer: C

Rationale: Hypertension is a serious complication of glomerulonephritis, as it can lead to further renal damage. A blood pressure reading of 150/95 mm Hg is elevated and should be reported promptly to the healthcare provider for immediate management to prevent complications. Dark-colored urine can be a common symptom of glomerulonephritis due to blood in the urine but is not as urgent as managing hypertension. Mild periorbital edema can also be seen in glomerulonephritis but is not as concerning as elevated blood pressure. Urine output of 250 mL in 24 hours indicates oliguria, which is a concern, but addressing hypertension takes priority to prevent further renal damage.

Similar Questions