Nursing Elites

1. A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

• A. Place the child in a quiet environment
• B. Make a list of foods that the child likes
• C. Encourage the parents to rest when possible
• D. Apply lotion to hands and feet

Correct answer: A

Rationale: The correct intervention for a child with Kawasaki disease, presenting with irritability and skin peeling, is to place the child in a quiet environment. This helps reduce environmental stimuli, calming the child and aiding in managing the symptoms associated with the disease. Choice B is incorrect as addressing food preferences is not the priority in this situation. Choice C is incorrect as the focus should be on the child's immediate needs. Choice D is incorrect as applying lotion is not the first-line intervention for Kawasaki disease symptoms.

2. Which assessment finding should the healthcare provider identify as most concerning in a child with acute glomerulonephritis?

• A. Hypertension.
• B. Gross hematuria.
• C. Proteinuria.
• D. Periorbital edema.

Correct answer: A

Rationale: In a child with acute glomerulonephritis, hypertension is the most concerning assessment finding as it can indicate worsening renal function. Hypertension is a common complication of glomerulonephritis and can lead to further kidney damage if not managed promptly. Monitoring and controlling blood pressure is crucial in these cases to prevent complications and preserve renal function. Gross hematuria, proteinuria, and periorbital edema are also common findings in acute glomerulonephritis but hypertension poses a higher risk for renal damage if left uncontrolled.

3. A 5-year-old child with leukemia is receiving chemotherapy. The nurse notes that the child’s white blood cell count is low. What is the nurse’s priority intervention?

• A. Administer antibiotics as prescribed
• B. Place the child in protective isolation
• C. Encourage the child to eat a balanced diet
• D. Teach the parents about infection prevention

Correct answer: B

Rationale: The priority intervention for a 5-year-old child with leukemia receiving chemotherapy and having a low white blood cell count is to place the child in protective isolation. This intervention helps reduce the risk of infection, which is crucial in this immunocompromised state. Protective isolation aims to limit the child's exposure to pathogens and promote their safety during a period of increased vulnerability to infections.

4. 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.

5. A 12-year-old male is brought to the clinic after falling during a skateboarding trick. The child's vital signs are heart rate 135 beats/minute, respirations 20 breaths/minute, and blood pressure 90/60. Which finding should the practical nurse report to the healthcare provider immediately?

• A. The client complains of his back being sore.
• B. Capillary refill is less than 2 seconds.
• C. Blood pressure is 94/68.
• D. Peripheral pulses are weak and rapid.

Correct answer: D

Rationale: In this scenario, the 12-year-old male with a heart rate of 135 beats/minute, respirations of 20 breaths/minute, and blood pressure of 90/60 after falling during a skateboarding trick exhibits signs of shock. Weak and rapid peripheral pulses are concerning as they may indicate decreased cardiac output and tissue perfusion, which are signs of shock. This finding should be reported to the healthcare provider immediately for further evaluation and intervention to prevent potential complications. The other choices are less urgent. Complaints of back soreness (choice A) could be related to musculoskeletal injury. Capillary refill less than 2 seconds (choice B) is within the normal range, indicating adequate peripheral perfusion. A blood pressure of 94/68 (choice C) is slightly higher than the initial reading and may be compensatory in response to the fall and shock state.

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