Nursing Elites

1. After reinforcing information on treating a sprained ankle, what statement by the adolescent indicates to the practical nurse that further instruction is needed?

• A. Keep the leg elevated when sitting.
• B. Wrap the ankle in an elastic bandage for support.
• C. Apply warm compresses to the ankle for the first 24 hours.
• D. Put an ice pack on the ankle, alternating 30 minutes on and 30 minutes off.

Correct answer: C

Rationale: The correct answer is C. Applying warm compresses to a sprained ankle within the first 24 hours is incorrect as it can increase swelling and inflammation. Instead, cold compresses are recommended to help reduce swelling and pain. Option A, keeping the leg elevated, helps in reducing swelling. Option B, wrapping the ankle in an elastic bandage, provides support. Option D, using an ice pack in intervals, is effective in reducing swelling and pain. Therefore, the statement about applying warm compresses indicates the need for further instruction.

2. When should a mother introduce solid foods to her 4-month-old baby girl? The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

• A. Stops rooting when hungry
• B. Opens mouth when food comes her way
• C. Awakens once for nighttime feedings
• D. Gives up a bottle for a cup

Correct answer: B

Rationale: The correct answer is B: 'Opens mouth when food comes her way.' This behavior indicates readiness to start trying solid foods. Infants should be introduced to solid foods based on developmental cues, such as showing an interest in food and the ability to accept it. Choices A, C, and D are not indicative of readiness for solid foods. Stopping rooting when hungry is a reflex that may persist beyond the readiness for solids. Awakening for nighttime feedings is a normal behavior for a 4-month-old, and transitioning from a bottle to a cup is a later developmental milestone.

3. When should a mother introduce solid foods to her 4-month-old infant? The mother states that her mother suggests putting rice cereal in the baby's bottle. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

• A. Stops rooting when hungry
• B. Opens mouth when food is offered
• C. Awakens once for nighttime feedings
• D. Gives up a bottle for a cup

Correct answer: B

Rationale: Introducing solid foods when the child opens their mouth for food is important to ensure readiness for solids. This behavior indicates the infant's interest and readiness for new textures and flavors, promoting safe and successful introduction to solid foods. The other choices are not indicative of the infant's readiness for solid foods: A - stopping rooting is a reflex action, C - awakening for nighttime feedings is a normal behavior, and D - transitioning from a bottle to a cup is a developmental milestone unrelated to solid food introduction.

4. The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

• A. Document the finding
• B. Palpate scrotum for testicular descent
• C. Assess for bladder distension
• D. Auscultate bowel sounds

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to document the finding. The infant voiding a urinary stream from the ventral surface of the penis suggests hypospadias, a condition where the urethral opening is on the underside of the penis. This finding is crucial information that needs to be documented for further evaluation. Palpating the scrotum for testicular descent, assessing for bladder distension, and auscultating bowel sounds are not appropriate actions based on the presented scenario and do not address the specific concern of the urinary stream location.

5. The nurse is preparing to administer an immunization to a 5-year-old child. The parent asks if the vaccine can be given in a different way because the child is afraid of needles. What is the nurse’s best response?

• A. We can apply a numbing cream before the injection
• B. There is no other way to administer this vaccine
• C. We can give the vaccine as a nasal spray
• D. We can skip the vaccine if the child is too afraid

Correct answer: C

Rationale: Administering the vaccine as a nasal spray provides an alternative method of delivery that avoids the use of needles, addressing the child's fear while ensuring immunization. Nasal sprays are effective for certain vaccines and can be a suitable option in this scenario. Choice A is not the best response as it only addresses pain management but does not eliminate the use of needles. Choice B is incorrect as there are alternative delivery methods like nasal sprays. Choice D is incorrect as skipping the vaccine would leave the child unprotected and is not a recommended course of action.

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