Nursing Elites

1. A mother has just given birth to a newborn with a cleft lip. Sensing that something is wrong, she starts to cry and asks the nurse, "What is wrong with my baby?" What is the most appropriate nursing action?

• A. Encourage the mother to express her feelings
• B. Explain in simple language that the baby has a cleft lip
• C. Provide emotional support until the practitioner can talk to the mother
• D. Tell the mother a pediatrician will talk to her as soon as the baby is examined

Correct answer: A

Rationale: Encouraging the mother to express her feelings allows her to process the situation and prepares her for receiving further information in a supportive environment.

2. The nurse is assessing a child suspected of having pinworms. Which is the most common symptom the nurse expects to assess?

• A. Restlessness
• B. Distractibility
• C. Rectal discharge
• D. Intense perianal itching

Correct answer: D

Rationale: Intense perianal itching is the most common symptom of pinworm infection, especially at night when the female worms lay their eggs

3. Which parameter correlates best with measurements of total muscle mass?

• A. Height
• B. Weight
• C. Skinfold thickness
• D. Upper arm circumference

Correct answer: D

Rationale: Upper arm circumference correlates best with total muscle mass because it includes both muscle and fat components, making it a reliable indicator of muscle mass.

4. Physiologically, the child compensates for fluid volume losses by which mechanism?

• A. Inhibition of aldosterone secretion
• B. Hemoconcentration to reduce cardiac workload
• C. Fluid shift from interstitial space to intravascular space
• D. Vasodilation of peripheral arterioles to increase perfusion

Correct answer: C

Rationale: In response to dehydration, the body compensates by shifting fluids from the interstitial spaces to the intravascular space to maintain blood pressure and perfusion to vital organs. Hemoconcentration and vasoconstriction are other compensatory mechanisms but are less immediate.

5. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care?

• A. Limit explanation of procedures because the child is preschool-aged
• B. Ask that all family members leave the room when performing procedures
• C. Allow the child to choose the type of juice to drink with the administration of oral medications
• D. Explain that EMLA cream cannot be used for the morning lab draw because there is not time for it to be effective

Correct answer: C

Rationale: Allowing the child to make choices, such as selecting the type of juice, helps to maintain a sense of control and reduce anxiety, ensuring atraumatic care.

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