Nursing Elites

1. The 6-year-old child scheduled for an orchiopexy shyly asks the nurse, 'What are they going to do to me 'down there'? What is the nurse's best response?

• A. They are going to fix you up 'down there'.
• B. They will move your testicle from your abdomen to your scrotum.
• C. What do you think your doctor is going to do?
• D. You shouldn't worry. Your doctor knows exactly what to do.

Correct answer: C

Rationale: The nurse should encourage the child to express his thoughts and feelings about the upcoming surgery. This approach helps the child feel heard and understood while providing an opportunity to address any misconceptions or fears. By asking the child what he thinks the doctor will do, the nurse engages the child in a conversation that can help alleviate anxiety and build trust. School-age children often have fears related to bodily harm, and open communication can help alleviate such concerns. Choices A and D do not encourage open communication or address the child's concerns directly. Choice B provides too much detail that may overwhelm the child and is not age-appropriate for a 6-year-old.

2. A nasogastric tube for suction is ordered for a neonate diagnosed with a diaphragmatic hernia. Which complication related to gastric drainage is the priority when planning care for this neonate?

• A. Weight loss
• B. Metabolic alkalosis
• C. Dehydration
• D. Hyperbilirubinemia

Correct answer: B

Rationale: Metabolic alkalosis is the priority complication to consider when a neonate with a diaphragmatic hernia is placed on gastric suction. Prolonged gastric drainage can lead to the loss of stomach acids, resulting in metabolic alkalosis, which can have serious consequences for the neonate's health.

3. What side effect should the nurse include in the parent teaching for a child prescribed a baclofen pump for cerebral palsy?

• A. Diarrhea
• B. Hypertonia
• C. Hypotonia
• D. Restlessness

Correct answer: C

Rationale: When a child is prescribed a baclofen pump for cerebral palsy, one of the common side effects to include in parent teaching is hypotonia. Baclofen, a muscle relaxant, can lead to decreased muscle tone, resulting in hypotonia. It is important for parents to be aware of this potential side effect and know how to respond accordingly.

4. At what age may an infant close their eyes to bright lights and show improved head control?

• A. 30-33 weeks after conception
• B. 34-36 weeks after conception
• C. Less than 30 weeks after conception
• D. 37-40 weeks after conception

Correct answer: A

Rationale: Around 30-33 weeks after conception, infants usually start closing their eyes in response to bright lights and exhibit enhanced head control. This developmental milestone indicates progress in their visual and motor abilities, reflecting the maturation of their neurological system. As preterm infants continue to grow and develop, they gradually acquire these skills, showcasing the natural progression of their sensory and motor functions.

5. Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client?

• A. We will change the colostomy bag with each wet diaper.
• B. We will expect a moderate amount of bleeding after cleansing the area around the stoma.
• C. We will watch for skin irritation around the stoma.
• D. We will use adhesive enhancers when we change the bag.

Correct answer: C

Rationale: Choosing option C, 'We will watch for skin irritation around the stoma,' demonstrates understanding of proper colostomy stoma care. Monitoring for skin irritation is crucial as it can indicate issues such as leakage, improper sealing, or infection. Options A, B, and D are incorrect. Changing the colostomy bag with each wet diaper (option A) is unnecessary unless indicated by a healthcare provider to prevent skin breakdown. Expecting bleeding after cleansing (option B) is not normal and may signal a problem that requires medical attention. Using adhesive enhancers (option D) should be done based on specific recommendations and not necessarily with every bag change.

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