Nursing Elites

1. A child is being cared for following a head injury. Which of the following findings should indicate to the healthcare provider that the child is developing diabetes insipidus?

• A. Urine specific gravity of 1.045
• B. Sodium level of 155
• C. Blood glucose level of 45
• D. Urine output of 35 ml per hour

Correct answer: B

Rationale: In a child with a head injury, the development of diabetes insipidus can occur due to pituitary hypofunction, leading to a deficiency of antidiuretic hormone. An elevated sodium level (hypernatremia) is a key finding in diabetes insipidus due to the excessive loss of free water in the urine, resulting in increased sodium concentration in the blood.

2. During the oliguric phase of acute kidney injury, what intervention should be included in the plan of care for a child?

• A. Administer a loop diuretic.
• B. Provide a low-sodium diet.
• C. Weigh the child weekly.
• D. Provide a high-protein diet.

Correct answer: A

Rationale: During the oliguric phase of acute kidney injury, the priority is managing fluid balance. Administering a loop diuretic is crucial to promote diuresis and reduce fluid retention, aiding in managing the condition effectively. Providing a low-sodium diet may be beneficial but is not the priority intervention during this phase. Weighing the child weekly is important for monitoring overall health but does not directly address the oliguric phase. Providing a high-protein diet is not typically recommended in acute kidney injury, especially during the oliguric phase, as it can put additional stress on the kidneys.

3. After administering Gardasil, the HPV vaccine, to an 11-year-old girl, the healthcare provider informs the parent that routine screening with which diagnostic test is needed?

• A. Beta hCG
• B. Chlamydia test
• C. PAP test
• D. Mammogram

Correct answer: C

Rationale: Following the administration of Gardasil, the HPV vaccine, routine screening with a PAP test is necessary. While Gardasil protects against certain types of HPV, it does not cover all strains that could lead to cervical cancer. Therefore, individuals who have received the vaccine should still undergo regular PAP tests to screen for cervical abnormalities caused by other HPV strains.

4. The healthcare provider is caring for a child on bed rest who has severe edema in the left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority?

• A. Risk for Impaired Skin Integrity
• B. Risk for Altered Body Image
• C. Risk for Imbalanced Nutrition: Less Than Body Requirements
• D. Risk for Activity Intolerance

Correct answer: A

Rationale: The priority nursing diagnosis in this scenario is 'Risk for Impaired Skin Integrity' because severe edema in the left lower extremity can lead to compromised circulation and pressure ulcers, increasing the risk of skin breakdown and infection. Addressing and preventing impaired skin integrity is crucial for the child's overall health and well-being.

5. During a developmental screening, a 4-year-old child is asked to perform a task. Which of the following tasks should the nurse expect the child to perform?

• A. Draw a stick figure with seven body parts
• B. Draw a circle
• C. Identify right from left hand
• D. Tie their shoelaces

Correct answer: B

Rationale: At 4 years old, children are typically able to draw a circle, which is a developmental milestone for their age. Drawing a stick figure with specific body parts might be beyond their developmental level, identifying right from left hand can be challenging, and tying shoelaces requires more advanced motor skills.

Similar Questions