Nursing Elites

1. A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?

• A. Monitor blood pressure every 30 minutes.
• B. Reposition the child every two hours.
• C. Limit visitors.
• D. Encourage fluids.

Correct answer: B

Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.

2. Which dietary information should the nurse include in the teaching plan for a school-age child with chronic renal failure?

• A. High in sodium
• B. Low in Vitamin D
• C. Low in phosphorus
• D. Supplementation of vitamins C, E, K

Correct answer: C

Rationale: A low-phosphorus diet is recommended for children with chronic renal failure to prevent hyperphosphatemia, which can lead to bone disease and other complications. Phosphorus is found in many processed foods and should be limited. Choices A, B, and D are incorrect because high sodium intake can lead to fluid retention and hypertension, while Vitamin D supplementation and vitamins C, E, K are not specifically indicated for dietary recommendations in chronic renal failure.

3. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

• A. Ask her, "Are you sexually active?"
• B. Ask her, "Are you having sex with anyone?"
• C. Ask her, "Are you having sex with a boyfriend?"
• D. Ask both the girl and her parent if she is sexually active

Correct answer: A

Rationale: Directly asking the adolescent if she is sexually active is the most straightforward and respectful approach, ensuring privacy and fostering trust.

4. What findings on physical assessment of a neonate would indicate the need for further evaluation?

• A. Nystagmus
• B. Epstein pearls
• C. Low-set ears
• D. Positive Babinski reflex

Correct answer: C

Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.

5. What organism is a parasite that causes acute diarrhea?

• A. Shigella organisms
• B. Salmonella organisms
• C. Giardia lamblia
• D. Escherichia coli

Correct answer: C

Rationale: Giardia lamblia is a protozoan parasite known to cause acute diarrhea, often through contaminated water or food. Shigella, Salmonella, and E. coli are bacterial pathogens that also cause diarrhea but are not parasites.

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