Nursing Elites

1. An infant who has had diarrhea for 3 days is admitted in a lethargic state and is breathing rapidly. The parent states that the baby has been ingesting formula, although not as much as usual, and cannot understand the sudden change. What explanation should the nurse give the parent?

• A. Cellular metabolism is unstable in young children.
• B. The proportion of water in the body is less than in adults.
• C. Renal function is immature in children until they reach school age.
• D. The extracellular fluid requirement per unit of body weight is greater than in adults.

Correct answer: D

Rationale: The correct answer is D. Infants have a higher extracellular fluid requirement per unit of body weight, making them more susceptible to dehydration and electrolyte imbalances during illnesses such as diarrhea. Choice A is incorrect because cellular metabolism being unstable is not the primary explanation for the symptoms described. Choice B is incorrect as the proportion of water in the body alone does not fully explain the increased risk of dehydration in infants. Choice C is incorrect because while renal function is immature in children, it is not the most relevant factor in this scenario compared to the increased fluid requirements.

2. A 5-year-old child is admitted to the hospital with a diagnosis of bacterial meningitis. What is the priority nursing intervention?

• A. Administering antibiotics
• B. Isolating the child
• C. Monitoring vital signs
• D. Administering fluids

Correct answer: B

Rationale: The priority nursing intervention for a 5-year-old child admitted to the hospital with bacterial meningitis is to isolate the child. Isolating the child is crucial to prevent the spread of infection to others, as bacterial meningitis is highly contagious. Administering antibiotics (Choice A) is important in the treatment of bacterial meningitis, but isolating the child takes precedence to protect others. Monitoring vital signs (Choice C) and administering fluids (Choice D) are essential aspects of care for a child with meningitis but are not the priority intervention to prevent the spread of the infection.

3. What is the most important intervention for a nurse to implement for a child with sickle cell anemia admitted to the hospital during a vaso-occlusive crisis?

• A. Administering oxygen
• B. Ensuring adequate hydration
• C. Monitoring vital signs
• D. Administering pain medication

Correct answer: B

Rationale: Ensuring adequate hydration is crucial during a vaso-occlusive crisis in sickle cell anemia as it helps to reduce the viscosity of the blood and prevent further sickling of the cells. While administering oxygen may be necessary in some cases, ensuring hydration takes precedence as it directly impacts the underlying pathophysiology of the crisis. Monitoring vital signs is important for ongoing assessment but does not directly address the crisis as hydration does. Administering pain medication is important for pain relief but does not address the primary issue of vaso-occlusion and is not the most crucial intervention in this scenario.

4. A nurse is assessing a child with suspected rheumatic fever. What clinical manifestation is the nurse likely to observe?

• A. Jaundice
• B. Peeling skin on the hands and feet
• C. High fever
• D. Severe joint pain

Correct answer: D

Rationale: The correct answer is D, severe joint pain. Rheumatic fever commonly presents with severe joint pain due to joint inflammation. Jaundice (choice A) is not typically associated with rheumatic fever. Peeling skin on the hands and feet (choice B) is more indicative of conditions like Kawasaki disease. While a high fever (choice C) can be present, it is not as specific to rheumatic fever as severe joint pain. Severe joint pain, along with other criteria like carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea, are major criteria used in the diagnosis of rheumatic fever.

5. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?

• A. Pertussis, tetanus, polio, and measles
• B. Diphtheria, pertussis, tetanus, and polio
• C. Rubella, polio, tuberculosis, and pertussis
• D. Measles, mumps, rubella, and tuberculosis

Correct answer: B

Rationale: The correct answer is B: Diphtheria, pertussis, tetanus, and polio. By 11 months of age, infants should have received doses of these vaccines as part of the immunization schedule. Choice A is incorrect because measles is usually given later in the schedule. Choice C is incorrect as rubella is usually given as part of the MMR vaccine, not individually, and tuberculosis is not routinely given as a vaccine in early infancy. Choice D is incorrect because mumps is not part of the recommended vaccines at 11 months of age.

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