Nursing Elites

1. A mother brings her 8-month-old baby boy to the clinic because he has been vomiting and having diarrhea for the last 3 days. Which assessment is most important for the nurse to make?

• A. Assess the infant's abdomen for tenderness
• B. Determine if the infant has been exposed to a virus
• C. Measure the infant’s pulse
• D. Evaluate the infant’s cry

Correct answer: C

Rationale: The most crucial assessment in this scenario is to measure the infant's pulse. Pulse measurement is essential to evaluate the severity of dehydration, which can be a significant concern in a baby experiencing vomiting and diarrhea for several days. Assessing the abdomen for tenderness may provide information on potential causes of symptoms but is not as urgent as monitoring hydration status. Determining exposure to a virus is important for infection control but does not directly address the immediate issue of dehydration. Evaluating the infant's cry, although a form of communication, does not provide critical information regarding the baby's physiological status in this situation.

2. When should a mother introduce solid foods to her 4-month-old baby girl? The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

• A. Stops rooting when hungry
• B. Opens mouth when food comes her way
• C. Awakens once for nighttime feedings
• D. Gives up a bottle for a cup

Correct answer: B

Rationale: The correct answer is B: 'Opens mouth when food comes her way.' This behavior indicates readiness to start trying solid foods. Infants should be introduced to solid foods based on developmental cues, such as showing an interest in food and the ability to accept it. Choices A, C, and D are not indicative of readiness for solid foods. Stopping rooting when hungry is a reflex that may persist beyond the readiness for solids. Awakening for nighttime feedings is a normal behavior for a 4-month-old, and transitioning from a bottle to a cup is a later developmental milestone.

3. A 4-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What is the nurse’s priority action?

• A. Perform a hearing test
• B. Inspect the child’s ears for drainage
• C. Refer the child to an audiologist
• D. Ask the parents about the child’s speech development

Correct answer: B

Rationale: The nurse's priority action should be to inspect the child's ears for drainage. This immediate assessment can provide valuable information about the presence of infection or fluid accumulation, which can directly impact the child's hearing. By identifying any signs of drainage, the nurse can promptly address any current issues affecting the child's ear health and hearing abilities. Performing a hearing test (Choice A) may be necessary but should follow the initial assessment of the ears. Referring the child to an audiologist (Choice C) can be considered later based on the findings. Asking about speech development (Choice D) is important but not the immediate priority compared to assessing for current ear issues.

4. The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first?

• A. Girls between ages 10 and 14.
• B. Boys between ages 10 and 14.
• C. Boys and girls between 12 and 14.
• D. Boys and girls between 8 and 12.

Correct answer: A

Rationale: Corrected Question: The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first? Girls between ages 10 and 14 are at the highest risk for scoliosis and should be screened first as they have a higher incidence of developing scoliosis during their adolescent growth spurt. Early detection and intervention can help prevent further complications associated with scoliosis. Boys between ages 10 and 14 (choice B) are not at the highest risk compared to girls in the same age group. Boys and girls between 12 and 14 (choice C) are at a lower risk compared to girls between ages 10 and 14. Boys and girls between 8 and 12 (choice D) are at a lower risk group compared to girls between ages 10 and 14.

5. What advice should be provided by the practical nurse to the mother of a school-age child with acute diarrhea and mild dehydration who is occasionally vomiting despite being given an oral rehydration solution (ORS)?

• A. Continue to give ORS frequently in small amounts.
• B. Alternate between ORS and carbonated beverages.
• C. Take the child to the hospital for intravenous fluids.
• D. Place the child NPO for the next eight to nine hours.

Correct answer: A

Rationale: The practical nurse should advise the mother to continue providing the oral rehydration solution (ORS) frequently in small amounts. It is essential to continue ORS administration to prevent dehydration, even if the child is occasionally vomiting. Small, frequent amounts of ORS help maintain hydration levels in children with acute diarrhea and mild dehydration.

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