Nursing Elites

1. A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?

• A. Monitoring for signs of infection
• B. Providing nutritional support
• C. Monitoring for signs of bleeding
• D. Monitoring for signs of pain

Correct answer: A

Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, increasing the risk of infections. Detecting and managing infections promptly is crucial to prevent complications and improve outcomes. Providing nutritional support is important, but infection prevention takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of bleeding is relevant in leukemia due to decreased platelet count, but infection surveillance is more critical. Monitoring for signs of pain is essential, but addressing infections promptly is the priority to prevent further deterioration in the child's condition.

2. While teaching a parent how to prevent accidents while caring for a 6-month-old infant, what motor development ability should be emphasized?

• A. Sits up
• B. Rolls over
• C. Crawls short distances
• D. Stands while holding on to furniture

Correct answer: B

Rationale: The correct answer is B: Rolls over. At 6 months, most infants can roll over, increasing the risk of falls. It is important to emphasize to the parent the need for careful supervision to prevent accidents. While choices A, C, and D are also milestones in infant motor development, rolling over at this age poses a higher risk of accidents due to the increased mobility and potential for falls.

3. A young child has coarctation of the aorta. What does the nurse expect to identify when taking the child’s vital signs?

• A. A weak radial pulse
• B. An irregular heartbeat
• C. A bounding femoral pulse
• D. An elevated radial blood pressure

Correct answer: A

Rationale: In coarctation of the aorta, there is narrowing of the aorta leading to decreased blood flow distal to the constriction. This results in a weak or delayed femoral pulse and a relatively weaker radial pulse compared to the femoral pulse. An irregular heartbeat (choice B) is not a typical finding in coarctation of the aorta. A bounding femoral pulse (choice C) would not be expected due to the decreased blood flow beyond the constriction. An elevated radial blood pressure (choice D) is not a common characteristic of coarctation of the aorta; instead, blood pressure may be higher in the upper extremities compared to the lower extremities due to the constriction.

4. The nurse is preparing a presentation to a local community group about genetic disorders and the types of congenital anomalies that can occur. What would the nurse include as a major congenital anomaly?

• A. Overlapping digits
• B. Polydactyly
• C. Umbilical hernia
• D. Cleft palate

Correct answer: D

Rationale: Cleft palate is considered a major congenital anomaly because it involves a gap or split in the roof of the mouth, which can significantly impact feeding, speech development, dental health, and overall well-being. Overlapping digits (Choice A) and polydactyly (Choice B) are examples of limb abnormalities rather than major congenital anomalies affecting vital functions. Umbilical hernia (Choice C) is a common condition where abdominal organs protrude through the belly button and is typically not considered a major congenital anomaly in the same way as cleft palate.

5. The nurse is assessing an infant and notes that the infant's urine has a mousy or musty odor. What would the nurse suspect?

• A. Maple syrup urine disease
• B. Tyrosinemia
• C. Phenylketonuria
• D. Trimethylaminuria

Correct answer: C

Rationale: The correct answer is C: Phenylketonuria (PKU). PKU is suggested by a mousy or musty odor of the urine, which is caused by the inability to metabolize phenylalanine. Choice A, Maple syrup urine disease, is characterized by a sweet-smelling urine. Choice B, Tyrosinemia, typically presents with cabbage-like odor in the urine. Choice D, Trimethylaminuria, is associated with a fishy odor in the urine, breath, and sweat.

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