Nursing Elites

1. An adolescent female who comes to the school clinic is reluctant to confide her concerns to the practical nurse (PN). The PN tells the teen that confidentiality and privacy are maintained unless a life-threatening situation arises. Which principle supports the PN's response?

• A. The adolescent should be encouraged to seek help outside of the school clinic.
• B. Disclosures from the adolescent should be kept confidential.
• C. Honest information ensures establishing a trusting relationship.
• D. Minor adolescents should not be encouraged to disclose private concerns.

Correct answer: C

Rationale: The correct principle supporting the practical nurse's response is that honest information ensures establishing a trusting relationship. By assuring confidentiality and privacy to the adolescent unless there is a life-threatening situation, the practical nurse fosters an environment where the teen feels safe to share their concerns openly. This approach helps build trust, encouraging effective communication and support for the adolescent's well-being. Choices A, B, and D are incorrect because encouraging seeking help outside the school clinic, keeping disclosures confidential, and discouraging minor adolescents from sharing private concerns do not address the immediate need to build trust and ensure the well-being of the adolescent in a school setting.

2. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?

• A. Remove the child who has HIV from the foster home.
• B. Report the exposure of the child with HIV to the health department.
• C. Place the child who has HIV in reverse isolation.
• D. Review the immunization documentation of the child who has HIV.

Correct answer: D

Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV to ensure they have received the necessary vaccines. This step is crucial in protecting the child's health and preventing further complications from vaccine-preventable diseases like pertussis. By reviewing the immunization documentation first, the nurse can determine the child's protection against pertussis and other infectious diseases. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately vaccinated. Reporting the exposure to the health department (Choice B) and placing the child in reverse isolation (Choice C) are important steps but reviewing the immunization status takes precedence to assess the child's protection and guide further actions.

3. The practical nurse is caring for a child with suspected appendicitis. Which assessment finding should be reported to the healthcare provider immediately?

• A. Nausea and vomiting.
• B. Sudden relief of pain.
• C. Low-grade fever.
• D. Rebound tenderness.

Correct answer: B

Rationale: Sudden relief of pain in a child with suspected appendicitis should be reported immediately as it may indicate a rupture of the appendix, which is a medical emergency. Sudden relief of pain is concerning because it can be a sign of a perforated appendix, leading to peritonitis and sepsis.

4. The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?

• A. Laughs readily, turns from back to side.
• B. Has strong Moro and tonic neck reflexes.
• C. Keeps fists clenched, opens hands when grasping an object.
• D. Can lift head, but not chest when lying on abdomen.

Correct answer: A

Rationale: In infants, laughing readily and turning from back to side are indicative of normal development. These behaviors indicate that the thyroid therapy is effective, as they suggest the baby is achieving age-appropriate milestones. A 5-month-old infant should be able to laugh readily and turn from back to side, showing progress in motor and social development. Choices B, C, and D describe behaviors that are not specific to the expected developmental milestones of a 5-month-old. Strong Moro and tonic neck reflexes, clenched fists, and limited ability to lift the chest when lying on the abdomen are not necessarily indicative of the effectiveness of thyroid therapy for hypothyroidism.

5. A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?

• A. Irregular palpable pulse
• B. Hyperactive bowel sounds
• C. Underweight for age
• D. Crying without tears

Correct answer: D

Rationale: Crying without tears is a sign of severe dehydration, which is a potentially life-threatening complication in infants with projectile vomiting. Dehydration can rapidly progress in infants, leading to serious consequences if not promptly addressed. The combination of projectile vomiting, listlessness, and absence of tears when crying should raise concerns about severe dehydration and the need for urgent intervention to prevent further complications.

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