Nursing Elites

1. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

• A. “Tell me about your daily routine.”
• B. “You look tired. Is everything alright?”
• C. “When was the last time the baby had a bottle?”
• D. “Oh, it looks like you two are having a bad day.”

Correct answer: A

Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.

2. On the third day of hospitalization, the nurse observes that a 2-year-old toddler who had been screaming and crying inconsolably begins to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?

• A. Denial
• B. Despair
• C. Mistrust
• D. Rejection

Correct answer: B

Rationale: The correct answer is B: 'Despair'. In separation anxiety, the stage of despair is characterized by regression and withdrawal after the initial protest. The toddler's shift from intense crying to lying quietly with a blanket demonstrates this withdrawal behavior. Choice A, 'Denial', is incorrect as denial involves refusing to accept the reality of separation. Choice C, 'Mistrust', is incorrect as it relates to a lack of trust rather than the stage of separation anxiety described in the scenario. Choice D, 'Rejection', is incorrect as it does not reflect the behavior of the toddler in the scenario, which is more indicative of withdrawal and regression.

3. After corrective surgery for hypertrophic pyloric stenosis (HPS), what should the nurse teach a parent to do immediately after a feeding to limit vomiting?

• A. Rock the infant.
• B. Place the infant in an infant seat.
• C. Place the infant flat on the right side.
• D. Keep the infant awake with sensory stimulation.

Correct answer: B

Rationale: After corrective surgery for hypertrophic pyloric stenosis (HPS), placing the infant in an infant seat is the correct action to take immediately after feeding to limit vomiting. This position helps keep the head elevated, reducing the risk of vomiting. Rocking the infant (Choice A) may agitate the stomach and increase the likelihood of vomiting. Placing the infant flat on the right side (Choice C) is not recommended as it does not encourage proper digestion and may increase the risk of vomiting. Keeping the infant awake with sensory stimulation (Choice D) does not address the positioning concern related to vomiting in this specific post-operative scenario.

4. A 5-year-old child with a diagnosis of asthma is being evaluated for medication management. What is an important assessment for the nurse to perform?

• A. Assess the child's sleep patterns
• B. Assess the child's dietary intake
• C. Assess the child's academic performance
• D. Assess the child's behavior at home

Correct answer: B

Rationale: Assessing the child's dietary intake is crucial for managing asthma symptoms as certain foods can trigger or worsen asthma attacks. Monitoring dietary intake helps ensure the child receives proper nutrition and avoids triggers. Assessing sleep patterns (Choice A) may be relevant but not as directly impactful on asthma management. Academic performance (Choice C) and behavior at home (Choice D) are important aspects of a child's overall health but are not as directly related to asthma management as dietary intake.

5. A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?

• A. Administering chemotherapy
• B. Preventing infection
• C. Monitoring for signs of bleeding
• D. Providing nutritional support

Correct answer: A

Rationale: The correct answer is A: Administering chemotherapy. In the care of a child with acute lymphoblastic leukemia (ALL), the priority nursing intervention is administering chemotherapy. Chemotherapy is the primary treatment for ALL and plays a crucial role in managing the disease. While preventing infection, monitoring for signs of bleeding, and providing nutritional support are important aspects of caring for a child with ALL, administering chemotherapy takes precedence as it directly targets the cancer cells and aims to induce remission.

Similar Questions