Nursing Elites

1. The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment?

• A. A white reflex
• B. Blue-tinged sclerae
• C. A red reflex
• D. Yellow-tinged sclerae

Correct answer: A

Rationale: The correct answer is A: A white reflex. The 'white reflex' or leukocoria is a common sign of retinoblastoma. It occurs when the light reflects off the tumor in the eye, giving the pupil a white appearance instead of the normal red reflex. Blue-tinged sclerae (choice B) and yellow-tinged sclerae (choice D) are not typical manifestations of retinoblastoma. A red reflex (choice C) is the normal reflection seen in the eye when light is shone on it and is not associated with retinoblastoma.

2. The nurse is discussing toddler development with a parent. Which intervention will foster the achievement of autonomy?

• A. Help the toddler complete tasks
• B. Encourage the toddler to do things for themselves when capable
• C. Provide opportunities for the toddler to play with other children
• D. Help the toddler learn the difference between right and wrong

Correct answer: B

Rationale: Encouraging the toddler to do things for themselves when capable is the correct intervention to foster autonomy. This approach helps the toddler develop independence, self-confidence, and a sense of achievement. Choice A is incorrect as it focuses on assisting rather than encouraging independence. Choice C is incorrect as playing with other children primarily fosters social skills, not necessarily autonomy. Choice D is incorrect as learning the difference between right and wrong is related to moral development, not autonomy.

3. While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?

• A. The 6-month-old in deep sleep
• B. The 2-year-old who is cooperative when the nurse takes vital signs
• C. The 4-year-old who is actively watching cartoons
• D. The 14-month-old who is screaming and thrashing his arms and legs

Correct answer: D

Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.

4. Which is a complication that can occur after abdominal surgery if pain is not managed?

• A. Atelectasis
• B. Hypoglycemia
• C. Decrease in heart rate
• D. Increase in cardiac output

Correct answer: A

Rationale: Poorly managed pain after abdominal surgery can lead to complications like atelectasis due to shallow breathing, which may occur if the child avoids deep breaths because of pain.

5. The nurse is discussing growth and development with a group of parents. What should the nurse say about developmental milestones?

• A. Increase in body size.
• B. Age-specific tasks that most children can do at a certain time.
• C. The direction of growth.
• D. Refers to the age group of children.

Correct answer: B

Rationale: The correct answer is B: "Age-specific tasks that most children can do at a certain time." Developmental milestones are specific tasks or abilities that most children can achieve at a certain age range. Choices A, C, and D are incorrect because developmental milestones are not just about increase in body size, the direction of growth, or the age group of children. They are more focused on the expected tasks and skills children can accomplish at particular ages.

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