Nursing Elites

1. The clinic nurse is assessing a child with a heavy ascariasis lumbricoides (common roundworm) infection. Which assessment findings should the nurse expect?

• A. Anemia
• B. Anorexia
• C. All are applicable
• D. Intestinal colic

Correct answer: D

Rationale: A heavy roundworm infection can cause anemia, anorexia, irritability, and an enlarged abdomen due to the worms’ effects on nutrient absorption and intestinal function.

2. What is a clinical manifestation of acetaminophen poisoning?

• A. Hyperpyrexia
• B. Hepatic involvement
• C. Severe burning pain in stomach
• D. Drooling and inability to clear secretions

Correct answer: B

Rationale: Acetaminophen poisoning primarily affects the liver, leading to hepatic involvement, which may present as jaundice, liver failure, or elevated liver enzymes. Hyperpyrexia, severe pain, and drooling are more associated with other types of poisoning.

3. Evidence-based practice (EBP), a decision-making model, is best described as which?

• A. Using information in textbooks to guide care
• B. Combining knowledge with clinical experience and intuition
• C. Using a professional code of ethics as a means for decision-making
• D. Gathering all evidence that applies to the child’s health and family situation

Correct answer: D

Rationale: Evidence-based practice involves gathering and integrating all relevant evidence to guide clinical decision-making, ensuring that care is based on the best available research.

4. A mother delivers an infant at 30 weeks gestation. The mother asks the nurse for information on nutrition and if formula would be better since the baby is premature. What is the foundation for the response to the mother by the nurse?

• A. Human milk is preferred over other types of nutrition.
• B. Human milk lacks essential nutrients when the infant is preterm.
• C. Commercial infant formulas are preferred over other types of nutrition.
• D. Commercial infant formulas have not been designed to meet the nutritional needs of preterm infants.

Correct answer: A

Rationale: The correct answer is A. Human milk is the preferred food for infants, including preterm infants. It contains essential ingredients necessary for the infant's growth and development. The mother should pump her breasts to provide milk for the infant if the child is receiving enteral feedings. Once the infant can coordinate breathing, sucking, and swallowing, breastfeeding directly is encouraged. Studies have shown that preterm infants fed fortified human milk have better outcomes compared to those fed commercial infant formulas. Commercial infant formulas may not fully meet the unique nutritional needs of preterm infants, leading to potential longer hospital stays. Therefore, human milk is the best choice for feeding premature infants.

5. What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?

• A. Measuring the abdomen after feedings
• B. Marking the point of measurement with a pen
• C. Measuring the circumference at the symphysis pubis
• D. Using a new tape measure with each assessment to ensure accuracy

Correct answer: B

Rationale: Marking the point of measurement ensures consistent and accurate assessments of abdominal circumference, especially important in conditions like bowel obstruction where changes need to be monitored closely.

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