Nursing Elites

1. A thorough systemic physical assessment is necessary in the extremely low-birth-weight (ELBW) infant to detect what?

• A. Weight gain reflective of fluid retention
• B. Difficulties in maternal-child attachment
• C. Subtle changes that may be indicative of an underlying problem
• D. Changes in Apgar score over the first 24 hours of life

Correct answer: C

Rationale: In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.

2. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?

• A. Avoid using any latex product.
• B. Use only non-allergenic latex products.
• C. Teach the family about long-term management of asthma.
• D. Administer medication for long-term desensitization.

Correct answer: A

Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.

3. Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis?

• A. “I will administer this medication 4 times a day.”
• B. “I will administer this medication twice a day.”
• C. “I will administer this medication with meals and snacks.”
• D. “I will administer this medication every 6 hours with meals.”

Correct answer: C

Rationale: The correct answer is C: "I will administer this medication with meals and snacks." Pancreatic enzymes should be administered with meals and snacks to aid in the digestion of nutrients in children with cystic fibrosis. Choices A, B, and D are incorrect because administering the medication without meals and snacks may not provide the necessary support for digestion needed in cystic fibrosis.

4. Play activities of the preschool-age child include:

• A. Having imaginary playmates
• B. Selective collection of objects
• C. Complex board games
• D. Associative play

Correct answer: A

Rationale: The correct answer is A, 'Having imaginary playmates.' Preschool-age children often engage in imaginative play, which includes creating imaginary friends or playmates. This type of play helps them develop creativity, social skills, and emotional expression. Choice B, 'Selective collection of objects,' may be more common in older children and is not a typical play activity for preschoolers. Choice C, 'Complex board games,' are usually beyond the developmental level of preschoolers as they require more advanced cognitive skills. Choice D, 'Associative play,' is a term used to describe a type of play where children play alongside each other but not necessarily together, which is different from the imaginative play involving imaginary playmates that preschoolers often engage in.

5. What is an advantage of the ventrogluteal muscle as an injection site in young children?

• A. Easily accessible from many directions
• B. Free of significant nerves and vascular structures
• C. Can be used until the child reaches a weight of 9 kg (20 lb)
• D. Increased subcutaneous fat, which provides sustained drug absorption

Correct answer: B

Rationale: The ventrogluteal site is free of significant nerves and vascular structures, making it a safer choice for intramuscular injections in young children compared to other sites that may be more prone to complications.

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