Nursing Elites

1. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. The woman states that her contractions are occurring every 4 to 5 minutes and lasting approximately 30 seconds each. Which of the following questions would be most appropriate to ask at this point?

• A. Has your bag of waters broken yet?
• B. Have you had regular prenatal care?
• C. At how many weeks gestation are you?
• D. How many other children do you have?

Correct answer: C

Rationale: In this scenario, asking about the gestational age is crucial as it helps determine the stage of labor and potential complications. Knowing the number of weeks of gestation can guide the healthcare provider in assessing the progress of labor and making decisions about the care of both the mother and the baby. Choices A, B, and D are not as relevant in this urgent situation. While knowing if the bag of waters has broken is important for assessing the progress of labor, determining gestational age is more critical at this point. Asking about regular prenatal care or the number of other children does not provide immediate information necessary for managing the current situation.

2. A child has been diagnosed with nephrotic syndrome, and a nurse is providing care. What is the priority nursing intervention?

• A. Administering diuretics
• B. Monitoring urine output
• C. Administering corticosteroids
• D. Restricting fluid intake

Correct answer: B

Rationale: The priority nursing intervention when caring for a child with nephrotic syndrome is monitoring urine output. This is essential for assessing kidney function and managing the condition effectively. Administering diuretics (Choice A) may be a part of the treatment plan but should not be the priority over monitoring urine output. Administering corticosteroids (Choice C) may also be a treatment for nephrotic syndrome, but monitoring urine output takes precedence. Restricting fluid intake (Choice D) may be necessary in some cases, but it is not the priority intervention compared to monitoring urine output for early detection of changes in kidney function.

3. A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect

• A. croup
• B. epiglottitis
• C. lower respiratory infection
• D. foreign body airway obstruction

Correct answer: D

Rationale: In a 3-year-old child presenting with sudden respiratory distress and no history of recent illnesses or fever, foreign body airway obstruction should be suspected. Foreign body airway obstruction commonly leads to acute respiratory distress without preceding symptoms. Croup (Choice A) typically presents with a barking cough and stridor. Epiglottitis (Choice B) often presents with high fever, drooling, and a muffled voice. Lower respiratory infection (Choice C) may manifest with symptoms such as cough, fever, and respiratory distress, but the sudden onset without fever or recent illness suggests a more acute event like foreign body airway obstruction.

4. Which is the most appropriate nursing diagnosis for a child with acute glomerulonephritis?

• A. Risk for injury related to malignant process and treatment
• B. Fluid volume deficit related to excessive losses
• C. Fluid volume excess related to decreased plasma filtration
• D. Fluid volume excess related to fluid accumulation in tissues and third spaces

Correct answer: C

Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is 'Fluid volume excess related to decreased plasma filtration.' Acute glomerulonephritis is characterized by inflammation in the glomeruli, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than deficit, making choice C the correct answer. Choice A is incorrect because acute glomerulonephritis is not primarily associated with a malignant process. Choice B is incorrect as the condition typically presents with fluid volume excess rather than deficit. Choice D is also incorrect as fluid accumulation in tissues and third spaces is not a typical manifestation of acute glomerulonephritis.

5. A 10-year-old girl is living with a foster family. Which intervention is the priority for the child in this family structure?

• A. Determining if the child is being bullied at school
• B. Dealing with mixed expectations of parents
• C. Establishing who is the child's actual caretaker
• D. Performing a comprehensive health assessment

Correct answer: D

Rationale: Performing a comprehensive health assessment is crucial for a child living with a foster family as they may have moved between different homes, leading to incomplete medical records. This assessment helps identify any existing health issues, ensure appropriate care, and address any unmet health needs. While addressing issues like bullying or parental expectations is important, the immediate priority should be ensuring the child's overall health and well-being. Establishing the actual caretaker is also important but may not be as urgent as addressing potential health concerns.

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