Nursing Elites

1. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature - hyperthermia
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.

2. You arrive at a residence shortly after a 4-year-old boy experienced an apparent febrile seizure. The child is alert and crying. His skin is flushed, hot, and moist. His mother tells you that the seizure lasted about 2 minutes. You should:

• A. provide supportive care and transport.
• B. give him acetaminophen or ibuprofen.
• C. begin rapid cooling measures at once.
• D. allow the mother to take her child to the doctor.

Correct answer: A

Rationale: After a febrile seizure, the recommended course of action is to provide supportive care and transport the child to a medical facility. Supportive care may include ensuring a safe environment, monitoring the child, and seeking medical evaluation to determine the underlying cause of the seizure and appropriate management.

3. Beta-adrenergic agonists such as albuterol are given to Reggie, a child with asthma, to primarily do which of the following?

• A. Dilate the bronchioles
• B. Reduce secondary infections
• C. Decrease postnasal drip
• D. Reduce airway inflammation

Correct answer: A

Rationale: Beta-adrenergic agonists like albuterol are bronchodilators that primarily work by relaxing and dilating the bronchioles, which helps to alleviate bronchoconstriction, a characteristic feature of asthma. This action leads to improved airflow and easier breathing for individuals experiencing asthma symptoms.

4. A healthcare provider is educating a new mother on discharge. They told the mother to look for the following danger signs.

• A. Poor Feeding
• B. High Temperature
• C. Convulsions
• D. All of the Above

Correct answer: D

Rationale: It is crucial for new mothers to be aware of potential danger signs after discharge. Poor feeding, high temperature, and convulsions are all critical symptoms that should prompt immediate medical attention. Poor feeding may indicate issues with feeding or underlying health problems. High temperature could be a sign of infection or illness. Convulsions are a serious symptom that could indicate neurological problems or other medical emergencies. By being vigilant and recognizing these signs early, the mother can help ensure the well-being of her newborn. Therefore, the correct answer is 'All of the Above' as all these signs require prompt medical attention to ensure the baby's health and safety.

5. A clinic nurse reviews the record of a child just seen by a doctor and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

• A. Pallor
• B. Hyperactivity
• C. Exercise intolerance
• D. Gastrointestinal disturbances

Correct answer: C

Rationale: Aortic stenosis is a condition characterized by the narrowing of the aortic valve, leading to reduced blood flow from the heart to the body. This narrowing restricts the amount of oxygenated blood that can reach various tissues, including muscles. As a result, individuals with aortic stenosis may experience exercise intolerance, as their muscles may not receive an adequate oxygen supply during physical activity. This can manifest as fatigue, shortness of breath, and overall decreased exercise capacity. Pallor (choice A) is a pale appearance that may be seen in anemia or other conditions affecting blood flow but is not specific to aortic stenosis. Hyperactivity (choice B) and gastrointestinal disturbances (choice D) are not typically associated with aortic stenosis.

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