Nursing Elites

1. A healthcare provider is planning care for a child with hyperkalemia. Which manifestation associated with the documented hyperkalemia requires immediate intervention by the healthcare provider?

• A. Hyperthermia
• B. Respiratory distress
• C. Seizures
• D. Cardiac arrhythmias

Correct answer: D

Rationale: In hyperkalemia, cardiac arrhythmias are the most critical and life-threatening manifestation that requires immediate intervention. Hyperkalemia can lead to dangerous heart rhythm disturbances, potentially resulting in cardiac arrest. Prompt treatment is essential to stabilize the heart rhythm and prevent life-threatening complications. Hyperthermia, respiratory distress, and seizures are not typically associated with hyperkalemia and should be addressed, but cardiac arrhythmias pose the most urgent risk to the patient's life.

2. A nurse is providing dietary teaching to the parent of a school-age child with cystic fibrosis. Which of the following statements should the nurse make?

• A. You should offer your child high-protein meals and snacks throughout the day
• B. Your child should decrease dietary fats to less than 10% of their caloric intake
• C. Your child will need to take a 1-gram sodium chloride tablet daily throughout their lifetime
• D. You should calculate your child's carbohydrate needs based on their daily activities

Correct answer: A

Rationale: The parent should provide a well-balanced diet that is high in protein and calories for a child with cystic fibrosis. This diet helps meet the child's increased energy requirements. Offering high-protein meals and snacks throughout the day is essential to ensure adequate nutrition and energy intake for children with cystic fibrosis. Choices B, C, and D are incorrect because children with cystic fibrosis actually need a higher fat intake for proper absorption of fat-soluble vitamins, sodium chloride supplementation is not a general recommendation for all children with cystic fibrosis, and carbohydrate needs are usually based on maintaining adequate weight and growth rather than daily activities.

3. The healthcare provider is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate?

• A. Measuring the girth just below the umbilicus
• B. Measuring the girth just below the sternum
• C. Measuring the girth just above the pubic bone
• D. Measuring the girth around the largest portion of the abdomen

Correct answer: D

Rationale: Measuring the girth around the largest portion of the abdomen ensures accurate assessment and tracking of abdominal distension. This method provides a more comprehensive measurement and helps healthcare providers monitor changes effectively.

4. During a well-child visit, a nurse is assessing a three-year-old toddler. Which of the following manifestations should the nurse report to the provider?

• A. Blood pressure 90/50
• B. Respiratory rate 45/min
• C. Weight 14.5 kg or 32 lb
• D. Heart rate 110/min

Correct answer: B

Rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and may indicate respiratory dysfunction or acute respiratory distress. It is essential for the nurse to report this finding promptly to the healthcare provider for further evaluation and intervention.

5. A teacher states to the school nurse, 'I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?' Which should the nurse include in the response to the teacher?

• A. The child has a crush on the teacher.
• B. The child has increased intracranial pressure.
• C. The child may have had a head injury.
• D. The child is experiencing absence seizures.

Correct answer: D

Rationale: Staring spells that end abruptly and are followed by normal activity are indicative of absence seizures. In absence seizures, a child may exhibit staring spells, brief loss of awareness, and lack of responsiveness, which can last for a few seconds. Choice A is incorrect because the behavior described is not associated with having a crush. Choice B is incorrect as increased intracranial pressure usually presents with other symptoms. Choice C is less likely as a head injury would typically manifest with additional signs beyond just staring and blinking.

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