Nursing Elites

1. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

• A. Recheck head control at the next visit
• B. Teach the parents appropriate exercises
• C. Schedule the child for further evaluation
• D. Refer the child for further evaluation if the anterior fontanel is still open

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

2. An important intervention for infants with developmental disabilities is to:

• A. Help parents realize their child will not develop further
• B. Stress the importance of early infant stimulation and intervention programs
• C. Have them institutionalized as soon as possible
• D. Have children reevaluated at 2 years of age to confirm the diagnosis

Correct answer: B

Rationale: The correct answer is B: Stress the importance of early infant stimulation and intervention programs. Early intervention programs are essential for infants with developmental disabilities as they can significantly impact the child's development and future outcomes. These programs provide necessary support and therapies to enhance the child's skills and abilities. Choice A is incorrect because it is crucial to provide hope and support to parents, emphasizing the potential for development and progress. Choice C is inappropriate and unethical as the first line of intervention. Institutionalization should only be considered in extreme cases where other options have been exhausted. Choice D is not the most crucial intervention at this stage. While reevaluation may be necessary, early intervention and support should be prioritized to maximize the child's developmental potential.

3. When checking the intravenous (IV) site on a child, the nurse should take which action?

• A. Look at the site.
• B. Ask the child if the site hurts.
• C. Look at the site while palpating the area.
• D. Take all the tape off, assess the site, and redress.

Correct answer: C

Rationale: Looking at and palpating the IV site helps assess for signs of infiltration or infection, such as swelling, redness, or pain. Simply looking or asking the child may miss subtle signs, and removing all the tape unnecessarily disrupts the site.

4. When assessing an infant with intussusception, what type of stool would the nurse expect to find?

• A. Soft, seedy stool
• B. Currant-jelly stool
• C. Ribbon-like stool
• D. Soft and pasty stool

Correct answer: B

Rationale: The correct answer is B: Currant-jelly stool. This type of stool, which is red and mucous-like, is a classic sign of intussusception in infants. Choice A (Soft, seedy stool) is incorrect as it does not specifically describe the characteristic stool associated with intussusception. Choice C (Ribbon-like stool) is incorrect; ribbon-like stool may be seen in conditions like colon cancer, not intussusception. Choice D (Soft and pasty stool) is also incorrect as it does not match the typical stool finding in intussusception.

5. An intravenous line is needed in a school-age child. What medication is an appropriate analgesic for use with this patient?

• A. TAC (tetracaine, epinephrine [Adrenalin], cocaine) 15 minutes before the procedure.
• B. A transdermal fentanyl (Duragesic) patch at the site of venipuncture.
• C. EMLA (eutectic mixture of local anesthetics) immediately before the procedure.
• D. LMX (4% liposomal lidocaine cream) 30 minutes before the procedure.

Correct answer: D

Rationale: LMX is an effective analgesic agent when applied to the skin 30 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin, making it more suitable for wound suturing. Transdermal fentanyl patches are designed for continuous pain control, not rapid pain control needed for a procedure like venipuncture. EMLA, for maximum effectiveness, must be applied approximately 60 minutes before the procedure, making it less suitable for immediate pain relief required for intravenous line placement.

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