Nursing Elites

1. When caring for a child diagnosed with sickle cell anemia, what is the priority nursing intervention?

• A. Administering pain medication
• B. Ensuring adequate hydration
• C. Providing nutritional support
• D. Monitoring vital signs

Correct answer: A

Rationale: The priority nursing intervention when caring for a child with sickle cell anemia is administering pain medication. Pain management is crucial in sickle cell anemia due to vaso-occlusive crises that can cause severe pain. While ensuring adequate hydration, providing nutritional support, and monitoring vital signs are important aspects of care for a child with sickle cell anemia, addressing the pain with appropriate medication takes precedence to alleviate the child's suffering and improve their quality of life.

2. When teaching the parents of a child with a diagnosis of type 1 diabetes mellitus about insulin administration, what should the nurse emphasize?

• A. Rotate injection sites
• B. Administer insulin before meals
• C. Store insulin in the refrigerator
• D. Administer insulin at bedtime

Correct answer: A

Rationale: The correct answer is to rotate injection sites. This practice helps prevent lipodystrophy, a localized loss of fat tissue that can affect insulin absorption. By rotating sites, the child can avoid developing lumps or indentations in the skin where insulin is repeatedly injected. Administering insulin before meals (choice B) may be necessary for certain types of insulin but is not the priority when teaching about insulin administration. Storing insulin in the refrigerator (choice C) is important for maintaining its potency, but it is not the primary emphasis when teaching about insulin administration. Administering insulin at bedtime (choice D) may be necessary based on the child's insulin regimen but is not the primary consideration for teaching injection techniques and site rotation.

3. A parent tells the nurse, “My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises.” How should the nurse explain these changes in behavior?

• A. “I will check these responses before deciding how to proceed.”
• B. “Failure of these responses may be related to a developmental delay.”
• C. “Additional sensory stimulation is needed to aid in the return of these responses.”
• D. “These responses are replaced by voluntary activity at about five months of age.”

Correct answer: D

Rationale: The correct answer is D: “These responses are replaced by voluntary activity at about five months of age.” The grasp reflex and startle reflex (Moro reflex) are normal in newborns but typically disappear as the infant's nervous system matures and voluntary control develops. Choice A is incorrect because checking the responses before deciding a course of action does not address the developmental milestone related to the reflexes. Choice B is incorrect as it jumps to a conclusion of developmental delay without considering the normal developmental process. Choice C is incorrect as additional sensory stimulation is not necessary for the return of these reflexes, as they are expected to naturally diminish as part of normal development.

4. What should be included in the preoperative teaching for a 4-year-old child scheduled for a tonsillectomy?

• A. Explaining the procedure in detail
• B. Encouraging deep breathing exercises
• C. Discussing the importance of hydration
• D. Using play therapy to prepare the child

Correct answer: B

Rationale: Encouraging deep breathing exercises is important preoperative teaching for a child scheduled for a tonsillectomy. Deep breathing exercises can help the child relax and reduce anxiety, which is beneficial before the procedure. Explaining the procedure in detail might be overwhelming for a 4-year-old, whereas encouraging deep breathing exercises can be more beneficial in promoting relaxation and preparing the child. Discussing the importance of hydration is crucial for postoperative care but may not be the priority for preoperative teaching. Using play therapy can help prepare the child, but encouraging deep breathing exercises is more directly related to relaxation and preparation for the procedure.

5. What foods are appropriate for a 30-month-old toddler on a regular diet?

• A. Hamburger with bun and grapes
• B. Chicken fingers and french fries
• C. Hot dog with bun and potato chips
• D. Macaroni and cheese and Cheerios

Correct answer: D

Rationale: Macaroni and cheese and Cheerios are appropriate choices for a 30-month-old toddler on a regular diet as they provide a balance of carbohydrates and protein. Option A, hamburger with bun and grapes, may be difficult for a toddler to chew, and grapes pose a choking hazard. Option B, chicken fingers and french fries, are high in unhealthy fats and sodium. Option C, hot dog with bun and potato chips, are processed foods high in salt and unhealthy fats, not ideal for a toddler's diet.

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