Nursing Elites

1. A healthcare provider is assessing a 3-month-old infant with suspected pyloric stenosis. What clinical manifestation is the healthcare provider likely to observe?

• A. Projectile vomiting
• B. Diarrhea
• C. Constipation
• D. Abdominal distension

Correct answer: A

Rationale: Projectile vomiting is a classic clinical manifestation of pyloric stenosis in infants. This occurs due to the narrowing of the pyloric sphincter, leading to the forceful expulsion of gastric contents in a projectile manner. Diarrhea (choice B) is not typically associated with pyloric stenosis. Constipation (choice C) is also not a common symptom of this condition. Abdominal distension (choice D) may occur in pyloric stenosis but is not as specific or characteristic as projectile vomiting in diagnosing this condition.

2. What is an early sign of congestive heart failure that the nurse should recognize?

• A. tachypnea
• B. bradycardia
• C. inability to sweat
• D. increased urinary output

Correct answer: A

Rationale: Tachypnea is an early sign of congestive heart failure that nurses should recognize. Tachypnea refers to rapid breathing, which can be an indication of the body's attempt to compensate for decreased cardiac output in congestive heart failure. Bradycardia (choice B) is a slow heart rate and is not typically associated with congestive heart failure. Inability to sweat (choice C) and increased urinary output (choice D) are not specific early signs of congestive heart failure and are not typically recognized as such.

3. A parent and 4-year-old child who recently emigrated from Colombia arrive at the pediatric clinic. The child has a temperature of 102°F, is irritable, and has a runny nose. Inspection reveals a rash and several small, red, irregularly shaped spots with blue-white centers in the mouth. What illness does the nurse suspect the child has?

• A. Measles
• B. Chickenpox
• C. Fifth disease
• D. Scarlet fever

Correct answer: A

Rationale: The nurse should suspect measles in this child. The presence of a high fever, irritability, runny nose, rash, and Koplik spots (small, red spots with blue-white centers in the mouth) are classic signs of measles. Measles is a highly contagious viral illness that can lead to serious complications if not managed promptly. Chickenpox (choice B) presents with a different rash pattern and does not typically involve Koplik spots. Fifth disease (choice C) and scarlet fever (choice D) also have distinct clinical presentations and are not characterized by the specific symptoms described in this case.

4. What explanation should the nurse give a parent about the purpose of a tetanus toxoid injection for their child?

• A. Passive immunity is conferred temporarily.
• B. Long-lasting active immunity is conferred.
• C. Lifelong active natural immunity is conferred.
• D. Passive natural immunity is conferred temporarily.

Correct answer: B

Rationale: The correct answer is B: Long-lasting active immunity is conferred. Tetanus toxoid injection works by stimulating the child's body to produce its antibodies, providing long-lasting active immunity. Choice A is incorrect because passive immunity is not conferred for life; it is temporary and involves receiving antibodies rather than producing them internally. Choice C is incorrect as the immunity conferred by the tetanus toxoid injection is not lifelong natural immunity but rather active immunity stimulated by the body's immune response. Choice D is also incorrect since passive natural immunity is not conferred by the tetanus toxoid injection, and it is not temporary.

5. A 2-year-old child with a diagnosis of autism spectrum disorder is being discharged. What should the nurse include in the discharge teaching?

• A. Maintain a structured routine
• B. Encourage social interaction
• C. Use positive reinforcement
• D. Use a communication board

Correct answer: A

Rationale: The correct answer is to maintain a structured routine. Children with autism spectrum disorder benefit from a structured routine as it provides them with stability and predictability, which can help reduce anxiety and improve behavior management. Encouraging social interaction (Choice B) may not be suitable for all children with autism, as some may struggle with social skills. While positive reinforcement (Choice C) is a helpful strategy, maintaining a structured routine is more essential for overall management in children with autism spectrum disorder. Using a communication board (Choice D) may be beneficial for communication, but establishing a structured routine is a foundational strategy that should be prioritized in the discharge teaching for a child with autism spectrum disorder.

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