Nursing Elites

1. 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.

2. A nurse is caring for a child who has a new diagnosis of osteomyelitis. Which of the following actions should the nurse take?

• A. Administer aspirin for pain.
• B. Apply ice to the affected area.
• C. Monitor the child�s weight daily.
• D. Limit the child's activity.

Correct answer: C

Rationale: The nurse should monitor the child�s weight daily to assess the effectiveness of treatment for osteomyelitis and detect potential complications.

3. A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?

• A. Spinal cord injury
• B. Increased intracranial pressure
• C. Typical for sleep
• D. Improvement

Correct answer: B

Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.

4. A nurse provides dietary teaching to the guardian of a school-age child with cystic fibrosis. Which statement should the nurse make?

• A. You should offer your child high-protein meals and snacks throughout the day.
• B. You should decrease your child's dietary fat intake to less than 10% of their caloric intake.
• C. You should restrict your child's calorie intake to 1,200 per day.
• D. You should give your child a multivitamin once weekly.

Correct answer: A

Rationale: The correct answer is A. High-protein meals and snacks are essential for children with cystic fibrosis due to their increased nutritional needs. Protein helps in maintaining muscle mass and overall health in individuals with cystic fibrosis, making it crucial to include in their diet. Choices B, C, and D are incorrect because decreasing dietary fat intake to less than 10% of caloric intake, restricting calorie intake to 1,200 per day, and giving a multivitamin once weekly are not appropriate dietary recommendations for a child with cystic fibrosis.

5. 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.

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