Nursing Elites

1. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?

• A. Attempt to open the jaw.
• B. Place the child on the floor.
• C. Call out for assistance from staff.
• D. Place a pillow under the child’s head.

Correct answer: B

Rationale: The best initial action during a tonic-clonic seizure is to place the child on the floor. This action helps prevent injury by providing a safe environment and allows for better management of the seizure episode. Attempting to open the jaw is not recommended as it may cause harm to the child or the nurse. Calling out for assistance is important but should not delay ensuring the child's safety first. Placing a pillow under the child's head is not advisable during a seizure as it can pose a risk of suffocation or choking.

2. 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.

3. A healthcare professional is teaching parents about why most children should be immunized against varicella (chickenpox) and why some receiving specific medications should not. Which medication should be included in the discussion?

• A. Insulin
• B. Steroids
• C. Antibiotics
• D. Anticonvulsants

Correct answer: B

Rationale: The correct answer is B: Steroids. Children receiving steroids should not receive the varicella vaccine as it can increase the risk of severe infection due to the immunosuppressive effects of steroids. Insulin (Choice A), antibiotics (Choice C), and anticonvulsants (Choice D) do not interact with the varicella vaccine in the same way as steroids, and therefore, they are not contraindicated.

4. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. Management should include

• A. Oxygen, uterine massage, and transport
• B. Oxygen, placement on the left side, and transport
• C. Oxygen, treatment for shock, and uterine massage during transport
• D. Oxygen, internal vaginal pads, and treatment for shock during transport

Correct answer: C

Rationale: In this scenario, the 21-year-old mother is showing signs of hemorrhagic shock with increased heart rate, diaphoresis, and vaginal bleeding. The appropriate management includes providing oxygen to support tissue perfusion, treating for shock to restore adequate circulation, and performing uterine massage to help control bleeding during transport. Options A, B, and D do not address the comprehensive management needed for postpartum hemorrhage in this situation.

5. What is important to include in discharge instructions for a child who has had a tonsillectomy?

• A. Encourage the child to gargle with salt water
• B. Encourage fluid intake
• C. Provide the child with hard candy
• D. Apply heat to the neck

Correct answer: B

Rationale: Encouraging fluid intake is essential post-tonsillectomy to keep the throat moist, aid in healing, and prevent dehydration. Gargling with salt water may irritate the surgical site and is typically avoided to prevent discomfort and irritation. Providing hard candy can be harmful as it may cause trauma to the surgical area and should be avoided to prevent injury. Applying heat to the neck is not recommended as it can increase swelling and discomfort in the surgical region. Therefore, the correct instruction is to encourage fluid intake.

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