Nursing Elites

1. A nurse is caring for an infant with intractable vomiting. For what complication is it most important for the nurse to assess?

• A. Acidosis
• B. Alkalosis
• C. Hyperkalemia
• D. Hypernatremia

Correct answer: B

Rationale: When an infant experiences intractable vomiting, it can lead to the loss of stomach acids, resulting in metabolic alkalosis. Alkalosis is characterized by elevated blood pH and can lead to serious complications. Assessing for alkalosis is essential in this scenario to monitor and manage the infant's condition. Choices A, C, and D are incorrect because in this context, the primary concern is the metabolic imbalance caused by excessive vomiting, leading to alkalosis rather than acidosis, hyperkalemia, or hypernatremia.

2. When assessing the perfusion status of a 2-year-old child with possible shock, which of the following parameters would be LEAST reliable?

• A. distal capillary refill
• B. systolic blood pressure
• C. skin color and temperature
• D. presence of peripheral pulses

Correct answer: B

Rationale: The correct answer is B: systolic blood pressure. In young children, systolic blood pressure is the least reliable parameter for assessing perfusion status. Factors such as anxiety, crying, and fear can significantly affect blood pressure measurements, leading to inaccuracies. Distal capillary refill, skin color and temperature, and presence of peripheral pulses are more reliable indicators of perfusion status in pediatric patients. Distal capillary refill assesses peripheral perfusion, skin color, and temperature reflect tissue perfusion, and the presence of peripheral pulses indicates blood flow to the extremities. Therefore, when evaluating a 2-year-old child with possible shock, focusing on parameters other than systolic blood pressure is crucial for an accurate assessment of perfusion status.

3. The nurse caring for families in crisis assesses the affective function of an immigrant family consisting of a father, mother, and two school-age children. Based on Friedman's structural functional theory, what defines this family component?

• A. Meeting the love and belonging needs of each member
• B. Teaching children how to function and assume adult roles in society
• C. Ensuring the family has necessary resources with appropriate allocation
• D. Involving the provision of physical care to keep the family healthy

Correct answer: A

Rationale: In Friedman's structural functional theory, the affective function of a family involves meeting the love and belonging needs of each member. This includes emotional support, care, and connections that contribute to the overall well-being of the family unit. Choice B is incorrect as it pertains more to the socialization function of the family, where children learn societal roles. Choice C relates to the economic function of the family, ensuring resources are available and allocated appropriately. Choice D focuses on the instrumental function of the family, which involves meeting the physical needs and health of its members.

4. A parent asks the nurse what to do when their toddler has temper tantrums. What play materials should the nurse suggest to offer the child as another way of expressing anger?

• A. Ball and bat
• B. Wad of clay
• C. Punching bag
• D. Pegs and pounding board

Correct answer: D

Rationale: Pegs and pounding boards are the most suitable choice for toddlers to express their emotions constructively. These materials provide a safe and acceptable way for toddlers to release anger and frustration through physical activity. Options A, B, and C may not be as effective or safe for toddlers dealing with temper tantrums. A ball and bat may encourage aggressive behavior rather than constructive expression. A wad of clay might not be ideal for channeling anger, and a punching bag can potentially promote violent behavior, which is not appropriate for toddlers.

5. Which of the following statements regarding 2-rescuer child CPR is correct?

• A. The chest should not be allowed to fully recoil in between compressions as this may impede venous return.
• B. Compress the chest with one or two hands to a depth equal to one-half to one third the diameter of the chest.
• C. The chest should be compressed with one hand and a compression to ventilation ratio of 30:2 should be delivered.
• D. A compression to ventilation ratio of 15:2 should be delivered without pauses in compressions to deliver ventilations.

Correct answer: B

Rationale: The correct statement regarding 2-rescuer child CPR is to compress the chest with one or two hands to a depth equal to one-half to one third the diameter of the chest. This technique ensures effective chest compressions without causing excessive damage to the chest. Choice A is incorrect because allowing the chest to fully recoil between compressions is essential to facilitate optimal blood flow during CPR. Choice C is incorrect as it describes a compression to ventilation ratio of 30:2, which is not the recommended ratio for child CPR. Choice D is incorrect as a compression to ventilation ratio of 15:2 is not standard practice for child CPR, and pauses in compressions are necessary to provide ventilations effectively.

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