Nursing Elites

1. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?

• A. Check the urine to see if hematuria has increased.
• B. Obtain the child's blood pressure and notify the healthcare provider.
• C. Obtain serum electrolytes and send urinalysis to the laboratory.
• D. Reassure the child and encourage bed rest until the headache improves.

Correct answer: B

Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.

2. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?

• A. Respiratory rate of 20 breaths per minute
• B. Heart rate of 89 beats per minute
• C. Heart rate of 120 beats per minute
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.

3. What approach is the most appropriate when performing a physical assessment on a toddler?

• A. Demonstrate the use of equipment
• B. Perform traumatic procedures last
• C. Use minimum physical contact initially
• D. Always proceed systematically in a head-to-toe direction

Correct answer: C

Rationale: The most appropriate approach when performing a physical assessment on a toddler is to use minimum physical contact initially. This helps gain the toddler's cooperation and reduces their distress. Performing traumatic procedures last is crucial as they are likely to upset the child and should be handled with care. Demonstrating the use of equipment may be complex for toddlers to understand, so it is not the most appropriate initial approach. Proceeding systematically in a head-to-toe direction is a good practice but using minimum physical contact initially is more important to establish trust and cooperation with the toddler.

4. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?

• A. Refer him for immediate medical evaluation
• B. Administer analgesics and recommend scrotal support.
• C. Apply an ice bag and observe for increasing pain.
• D. Reassure the adolescent that occasional pain is common with the changes of puberty.

Correct answer: A

Rationale: Sudden and severe scrotal pain in an adolescent male is a medical emergency and may indicate testicular torsion, which requires immediate evaluation and intervention to prevent testicular loss.

5. The nurse is explaining different parenting styles to a group of parents. The nurse explains that an authoritative parenting style can lead to which child behavior?

• A. Shyness
• B. Self-reliance
• C. Submissiveness
• D. Self-consciousness

Correct answer: B

Rationale: An authoritative parenting style, which balances warmth with firmness, is associated with fostering self-reliance and independence in children.

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