Nursing Elites

1. The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?

• A. One portion of the intestines invaginates or telescopes into another
• B. Hypertrophy of the circular pylorus muscle
• C. Relaxed cardiac sphincter
• D. Absent ganglion cells in the colon

Correct answer: B

Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.

2. What is the most frequent cause of hypovolemic shock in children?

• A. Sepsis
• B. Blood loss
• C. Anaphylaxis
• D. Heart failure

Correct answer: B

Rationale: Hypovolemic shock in children is most frequently caused by blood loss, which can result from trauma, surgery, or gastrointestinal bleeding. Sepsis and anaphylaxis can lead to different types of shock (septic and anaphylactic), and heart failure is related to cardiogenic shock.

3. What is the first step in managing a child with anaphylaxis?

• A. Administer antihistamines
• B. Establish IV access
• C. Administer epinephrine
• D. Monitor vital signs

Correct answer: C

Rationale: The correct answer is to administer epinephrine. Administering epinephrine is the crucial first step in managing anaphylaxis as it helps reverse the severe allergic reaction by constricting blood vessels and relaxing airway muscles, preventing a life-threatening situation. Antihistamines (Choice A) are not the first-line treatment for anaphylaxis and should not delay the administration of epinephrine. Establishing IV access (Choice B) may be necessary but is not the initial step in managing anaphylaxis. Monitoring vital signs (Choice D) is important but should not take precedence over administering epinephrine in the acute management of anaphylaxis.

4. As the primary caregiver for a 5-month-old baby, according to Maslow’s hierarchy of basic needs, which intervention takes the highest priority?

• A. Feeding every four hours
• B. Protection from harm
• C. Providing stimulation
• D. Providing love

Correct answer: A

Rationale: The correct answer is A: Feeding every four hours. According to Maslow’s hierarchy of needs, physiological needs, such as food, water, and warmth, take the highest priority. Ensuring that the baby is fed regularly is crucial for survival and overall health. Choice B, protection from harm, relates more to safety needs which come after physiological needs. Choice C, providing stimulation, is associated with higher-level needs like belongingness and esteem. Choice D, providing love, corresponds to esteem and self-actualization needs, which are higher in the hierarchy than physiological needs.

5. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?

• A. Feet and hands
• B. Bridge of nose
• C. Circumoral area
• D. Mucous membranes

Correct answer: A

Rationale: Nonpathologic cyanosis in newborns shortly after birth is typically present in the feet and hands, known as acrocyanosis. This is a normal finding due to the immature peripheral circulation in newborns. Cyanosis of the bridge of the nose, circumoral area, and mucous membranes indicates generalized cyanosis, which suggests a potential underlying distress or major abnormality. Therefore, choice A is correct as it describes the expected location for nonpathologic cyanosis in newborns, while choices B, C, and D represent areas associated with abnormal cyanosis.

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