Nursing Elites

1. What is an important nursing consideration for a child with a diagnosis of juvenile idiopathic arthritis (JIA) being treated with methotrexate?

• A. Monitor liver function tests regularly
• B. Encourage regular exercise
• C. Provide high-calorie snacks
• D. Encourage frequent handwashing

Correct answer: A

Rationale: The correct answer is to monitor liver function tests regularly. Methotrexate, commonly used in JIA, can be hepatotoxic. Regular monitoring of liver function tests is crucial to detect any signs of liver damage early. While encouraging regular exercise (choice B) is generally beneficial for overall health, it is not directly related to methotrexate therapy. Providing high-calorie snacks (choice C) is not a necessary consideration in this context and can be misleading. Encouraging frequent handwashing (choice D) is important for infection control but is not specifically related to the medication methotrexate.

2. What explanation should be given to a parent about the purpose of a tetanus toxoid injection for their child?

• A. Passive immunity is conferred for life.
• B. Long-lasting active immunity is conferred.
• C. Lifelong active natural immunity is conferred.
• D. Passive natural immunity is conferred temporarily.

Correct answer: B

Rationale: The correct answer is B: 'Long-lasting active immunity is conferred.' Tetanus toxoid injection provides long-lasting active immunity by stimulating the body to produce its own antibodies. Choice A is incorrect because tetanus toxoid injection does not provide passive immunity. Choice C is incorrect because the immunity conferred by the vaccine is not natural but artificially induced. Choice D is incorrect as the immunity provided by the tetanus toxoid injection is active, not passive.

3. A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?

• A. Recommend raising the bed's side rails when a caregiver is not present.
• B. Suggest a caregiver be present continuously to prevent falls from bed.
• C. Encourage the use of loose restraints while in bed.
• D. Recommend raising the bed's side rails throughout the day and night.

Correct answer: A

Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.

4. During a clinical conference with a group of nursing students, the instructor is describing burn classification. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?

• A. Skin that is reddened, dry, and slightly swollen
• B. Skin appearing wet with significant pain
• C. Skin with blistering and swelling
• D. Skin that is leathery and dry with some numbness

Correct answer: D

Rationale: Full-thickness burns are characterized by a leathery, dry appearance with numbness due to nerve damage. Choice A describes characteristics of superficial burns, which are not full-thickness. Choice B describes characteristics of partial-thickness burns with intact blisters, not full-thickness burns. Choice C describes characteristics of partial-thickness burns with blistering and swelling, not full-thickness burns.

5. A newborn with an anorectal anomaly had an anoplasty performed. At the 2-week follow-up visit, a series of anal dilations is begun. What should the nurse recommend to the parents to help prevent the infant from becoming constipated?

• A. Use a soy formula if necessary.
• B. Breastfeed if possible.
• C. Avoid administering a suppository nightly.
• D. Do not offer glucose water between feedings.

Correct answer: B

Rationale: Breastfeeding is recommended to help prevent constipation in infants due to the easily digestible nature of breast milk, which often leads to softer stools. Breastfeeding is preferred over formula feeding as it provides optimal nutrition for the infant's digestive system. Choice A, using a soy formula if necessary, may be considered only if there are specific dietary concerns or allergies; however, breast milk is still the preferred option. Choice C, avoiding administering a suppository nightly, is correct as it is not a routine method for preventing constipation in infants and may not be appropriate without medical advice. Choice D, not offering glucose water between feedings, is recommended as it may not address the root cause of constipation and may introduce unnecessary sugar to the infant's diet.

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