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. The parents of a 2-month-old infant, who is being discharged after treatment for pyloric stenosis, are being educated by the healthcare provider. Which statement by the parents indicates a need for further teaching?

• A. We should feed our baby in an upright position
• B. We should avoid feeding our baby solid foods until at least 6 months of age
• C. We will lay our baby on their stomach to sleep
• D. We will burp our baby frequently during feedings

Correct answer: C

Rationale: The correct answer is C. Placing babies on their stomach to sleep increases the risk of sudden infant death syndrome (SIDS). The safest sleep position for infants is on their back to reduce the risk of SIDS. Teaching parents about safe sleep practices is crucial in preventing potential harm to the infant. Choices A, B, and D are all correct statements that promote the well-being of the infant. Feeding the baby in an upright position helps prevent reflux, delaying solid foods until 6 months of age is recommended for proper growth and development, and burping the baby frequently during feedings helps prevent gas buildup and colic.

3. In a 12-year-old child with a history of epilepsy brought to the emergency department after experiencing a 10-minute seizure, what is the nurse’s priority intervention?

• A. Administer oxygen
• B. Administer antiepileptic medication as prescribed
• C. Monitor the child’s vital signs
• D. Check the child’s blood glucose level

Correct answer: B

Rationale: Administering antiepileptic medication as prescribed is the priority intervention in a child with a history of epilepsy who experienced a prolonged seizure. This action is crucial to stop the seizure and prevent further complications associated with prolonged seizure activity. Administering oxygen may be necessary, but the priority is to stop the seizure. Monitoring vital signs and checking blood glucose levels are important but secondary to administering antiepileptic medication to manage the seizure.

4. The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

• A. Document the finding
• B. Palpate scrotum for testicular descent
• C. Assess for bladder distension
• D. Auscultate bowel sounds

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to document the finding. The infant voiding a urinary stream from the ventral surface of the penis suggests hypospadias, a condition where the urethral opening is on the underside of the penis. This finding is crucial information that needs to be documented for further evaluation. Palpating the scrotum for testicular descent, assessing for bladder distension, and auscultating bowel sounds are not appropriate actions based on the presented scenario and do not address the specific concern of the urinary stream location.

5. Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

• A. Encourage oral electrolyte solution intake
• B. Assist the child to a recumbent position
• C. Contact their healthcare provider immediately
• D. Provide a quiet time by holding or rocking the toddler

Correct answer: C

Rationale: If a child with tetralogy of Fallot becomes pale, cool, and lethargic, these symptoms may indicate a hypoxic episode or worsening condition. It is crucial to contact the healthcare provider immediately for further evaluation and management to ensure the child's safety and well-being. Option A is incorrect because electrolyte solution intake is not the immediate action needed for these symptoms. Option B is incorrect as positioning alone may not address the underlying issue. Option D is incorrect as providing a quiet time is not appropriate if the child is experiencing concerning symptoms that require prompt medical attention.

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