Nursing Elites

1. A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?

• A. Reassure the father that Visine is harmless.
• B. Direct him to seek immediate medical treatment.
• C. Recommend inducing vomiting with ipecac.
• D. Advise him to dilute Visine by giving his daughter several glasses of water to drink.

Correct answer: B

Rationale: Visine is not harmless when ingested, and immediate medical treatment is necessary due to the risk of toxicity. Vomiting should not be induced without medical advice, and dilution with water is not an appropriate treatment.

2. Which condition is most commonly associated with a 'sunset sign' in infants?

• A. Hydrocephalus
• B. Meningitis
• C. Cerebral palsy
• D. Encephalitis

Correct answer: A

Rationale: The 'sunset sign,' characterized by downward-driven eyes, is most commonly associated with hydrocephalus. This condition causes increased intracranial pressure, leading to the eyes appearing to be forced downward. Meningitis (choice B) typically presents with symptoms such as fever, headache, and a stiff neck, but not the 'sunset sign.' Cerebral palsy (choice C) is a group of disorders affecting movement and muscle coordination, not directly related to the 'sunset sign.' Encephalitis (choice D) is inflammation of the brain, which can cause symptoms like fever, headache, and confusion, but not the specific downward eye gaze seen in the 'sunset sign.'

3. What is the best age to introduce solid food into an infant’s diet?

• A. 2 to 3 months
• B. 4 to 6 months
• C. When birth weight has tripled
• D. When tooth eruption has started

Correct answer: B

Rationale: The introduction of solid foods is recommended at 4 to 6 months when the infant's digestive system is more developed and ready for solids.

4. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

• A. Ask the parent when the neck was injured
• B. Refer for immediate medical evaluation
• C. Continue assessment to determine the cause of the neck pain
• D. Record head lag on the assessment record and continue the assessment of the child

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

5. What is the best initial intervention for a child experiencing moderate dehydration?

• A. Administer IV fluids
• B. Encourage oral rehydration
• C. Monitor vital signs
• D. Provide clear fluids

Correct answer: B

Rationale: The correct answer is B: Encourage oral rehydration. Oral rehydration is the first-line treatment for moderate dehydration in children. It helps restore fluid balance and electrolyte levels. Administering IV fluids (Choice A) is usually reserved for severe cases of dehydration where oral rehydration is not feasible or ineffective. Monitoring vital signs (Choice C) is important but should not replace the immediate need for rehydration. Providing clear fluids (Choice D) may not contain the necessary electrolytes required for effective rehydration.

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