Nursing Elites

1. A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile with a capillary refill of 2 seconds. Which information should the nurse discuss with the mother?

• A. Encourage the infant to play
• B. Limit the amount of oral intake
• C. Keep the infant isolated from others
• D. Place the infant on their back for naps

Correct answer: C

Rationale: Bronchiolitis is a highly contagious respiratory infection commonly caused by viruses. Isolating the infant from others is crucial to prevent the spread of the infection to other vulnerable individuals, especially those with weakened immune systems. Encouraging play may not be appropriate as the infant is sick and needs rest. Limiting oral intake might be necessary if the infant is having difficulty swallowing due to respiratory distress. Placing the infant on their back for naps is a safe sleep practice but not the priority in this situation where preventing transmission of the infection is crucial.

2. When obtaining the nursing history of a 7-year-old child admitted to the hospital with acute glomerulonephritis (AGN), which finding should the nurse expect to obtain?

• A. High blood cholesterol level on routine screening.
• B. Increased thirst and urination.
• C. A recent strep throat infection.
• D. A recent DPT immunization.

Correct answer: C

Rationale: When assessing a child with acute glomerulonephritis (AGN), a common trigger to expect in the nursing history is a recent strep throat infection. AGN can be triggered by a streptococcal infection, leading to the deposition of immune complexes in the glomeruli. This finding is crucial as it helps identify a potential cause for the development of AGN in the child. Choices A, B, and D are incorrect as high blood cholesterol levels, increased thirst and urination, and recent DPT immunization are not directly associated with triggering acute glomerulonephritis in children.

3. The practical nurse is reinforcing information about Lyme disease prevention with a client who is preparing for a camping trip with family. Which statement by the client informs the nurse that the client understands the instruction?

• A. I'll make sure my son wears dark clothing on his hike.
• B. I'll get a prescription for amoxicillin to take with us.
• C. We should all get the Lyme disease vaccine before our trip.
• D. We will wear long pants and long-sleeved shirts in the woods.

Correct answer: D

Rationale: The correct answer is D. Wearing long pants and long-sleeved shirts is an effective preventive measure against tick bites, which reduces the risk of contracting Lyme disease. This attire helps to minimize skin exposure to ticks, thereby decreasing the chances of a tick attaching and transmitting the disease-causing bacteria.

4. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

• A. The mother is a single parent and lives with her parents
• B. The mother states the baby is irritable during feedings
• C. The infant’s formula has been changed twice
• D. The diaper area shows severe skin breakdown

Correct answer: D

Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.

5. A 10-year-old child is admitted to the hospital with a diagnosis of acute glomerulonephritis. The nurse notes that the child has edema and elevated blood pressure. What is the nurse’s priority action?

• A. Administer antihypertensive medication as prescribed
• B. Monitor the child’s urine output
• C. Elevate the child’s legs to reduce edema
• D. Restrict the child’s fluid intake

Correct answer: A

Rationale: In a child with acute glomerulonephritis presenting with edema and elevated blood pressure, the priority action for the nurse is to administer antihypertensive medication as prescribed. Managing blood pressure is essential to prevent further complications associated with the condition, such as worsening kidney function and cardiovascular strain. Monitoring urine output is important but not the priority over managing elevated blood pressure. Elevating the child's legs may help with edema but addressing the elevated blood pressure takes precedence. Fluid intake restriction may be necessary in some cases, but it is not the immediate priority when managing acute glomerulonephritis with edema and hypertension.

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