Nursing Elites

1. During which phase of the nursing process does the nurse use essential information about the child’s physical, social, and emotional health to decide which interventions to use?

• A. Implementation
• B. Planning
• C. Diagnosis
• D. Assessment

Correct answer: B

Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse utilizes essential information gathered during the assessment about the child’s physical, social, and emotional health to determine the most appropriate interventions to address the identified needs. This phase focuses on developing a comprehensive care plan tailored to the individual child. A) Implementation is incorrect because this phase involves carrying out the interventions outlined in the care plan. C) Diagnosis is incorrect as it refers to identifying health issues based on the assessment data. D) Assessment is incorrect as it involves collecting and analyzing data about the child's health status, rather than deciding on interventions.

2. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

• A. Weight loss and decreased heart rate
• B. Capillary refill of less than 2 seconds and no tears
• C. Increased skin elasticity and sunken anterior fontanel
• D. Dry mucous membranes and generally ill appearance

Correct answer: D

Rationale: Dry mucous membranes and an ill appearance are good indicators of dehydration in infants, often correlating with a fluid deficit of at least 5%. Sunken fontanels and poor skin turgor are also indicative but were not options here.

3. Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?

• A. Hepatitis B
• B. Polio
• C. Measles, mumps, and rubella (MMR)
• D. Hemophilus influenzae type B (Hib)

Correct answer: D

Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.

4. When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?

• A. Petechiae, fever, fatigue
• B. Headache, papilledema, irritability
• C. Muscle wasting, weight loss, fatigue
• D. Decreased intracranial pressure, psychosis, confusion

Correct answer: A

Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.

5. A toddler’s mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse’s response should be based on which premise?

• A. An emergency laparotomy is very likely.
• B. The location needs to be confirmed by radiographic examination.
• C. Surgery will be necessary if the battery has not passed in the stool in 48 hours.
• D. Careful observation is essential because an ingested battery cannot be accurately detected.

Correct answer: B

Rationale: Radiographic examination is essential to confirm the location of the battery, as it can cause significant damage, particularly if lodged in the esophagus. Immediate surgery may be required depending on its location and the potential for causing harm.

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