Nursing Elites

1. Parents of a school-age child ask the nurse for suggestions in helping the child who is demonstrating school avoidance. What is an appropriate suggestion by the nurse?

• A. Take the child to the healthcare provider for testing.
• B. Be firm and insist the child go to school.
• C. Allow the child to stay home and rest.
• D. Consult with the teacher at school.

Correct answer: B

Rationale: When a child is demonstrating school avoidance, it is important for parents to be firm and insist that the child go to school. This helps establish a routine and prevents the behavior from becoming a pattern. Taking the child to the healthcare provider for testing (Choice A) may not be necessary at this stage as school avoidance is a behavioral issue. Allowing the child to stay home and rest (Choice C) may reinforce the avoidance behavior. While consulting with the teacher at school (Choice D) is important, the immediate focus should be on addressing the avoidance behavior at home.

2. How should the nurse measure urinary output for an infant with dehydration?

• A. Attaching a urine collecting bag
• B. Wringing out the diaper
• C. Weighing the diaper
• D. Inserting a catheter

Correct answer: C

Rationale: The correct way to measure urinary output for an infant with dehydration is by weighing the diaper. Wet diapers are weighed to assess the amount of output accurately. Attaching a urine collecting bag and inserting a catheter are invasive methods not typically used for routine measurement of urinary output in infants. Wringing out the diaper can lead to inaccurate measurements and is not a recommended method for assessing urinary output.

3. What is the most critical initial intervention for a client who is actively seizing?

• A. Restrain the client to prevent injury
• B. Insert an oral airway
• C. Turn the client to the side
• D. Apply soft restraints to the wrists

Correct answer: C

Rationale: The most critical initial intervention for a client who is actively seizing is to turn the client to the side. This action helps maintain an open airway and prevents aspiration during a seizure. Restrain the client to prevent injury (Choice A) is incorrect because restraining a client during a seizure can lead to injury. Inserting an oral airway (Choice B) is not recommended as it can cause injury and is not necessary during an active seizure. Applying soft restraints to the wrists (Choice D) is also not recommended as it can lead to harm and does not address the immediate airway management needed during a seizure.

4. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?

• A. A history of diarrhea following each feeding
• B. Gastric pain evidenced by vigorous crying
• C. Poor appetite due to a poor sucking reflex
• D. An olive-shaped mass right of the midline

Correct answer: D

Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.

5. Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children. The nurse should assess closely for what potential problem?

• A. Physical problems
• B. Relational problems
• C. Eating disorders
• D. Emotional problems

Correct answer: D

Rationale: The correct answer is D: 'Emotional problems.' Recurrent abdominal pain (RAP) in children is frequently associated with emotional factors rather than physical issues, relational problems, or eating disorders. Children may manifest emotional distress through physical symptoms like abdominal pain, making it crucial for nurses to assess for emotional problems as a potential cause.

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