Nursing Elites

1. The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.)

• A. The child has a stiff neck.
• B. The fever is over 40.6 C (105 F).
• C. The child is younger than 2 months.
• D. All of the above

Correct answer: D

Rationale: High fever, especially in very young infants, or the presence of a stiff neck can indicate a serious infection requiring immediate attention. A fever lasting more than 3 days also warrants medical evaluation.

2. What is the narrowing of the preputial opening of the foreskin called?

• A. Chordee
• B. Phimosis
• C. Epispadias
• D. Hypospadias

Correct answer: B

Rationale: Phimosis is the condition where the foreskin cannot be fully retracted over the glans penis due to a narrowing of the preputial opening. Chordee, epispadias, and hypospadias are different conditions involving the penis's structure.

3. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?

• A. Ask her why she wants to know.
• B. Determine why she is so anxious.
• C. Explain in simple terms how it works.
• D. Tell her she will see how it works as it is used.

Correct answer: C

Rationale: Providing a simple explanation satisfies the child's curiosity and helps reduce any anxiety about the procedure.

4. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis?

• A. Infarction of renal vessels
• B. Immune complex formation and glomerular deposition
• C. Bacterial endotoxin deposition on and destruction of glomeruli
• D. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation

Correct answer: B

Rationale: Postinfectious glomerulonephritis is typically caused by immune complex deposition in the glomeruli following a streptococcal infection. This immune response leads to inflammation and impaired kidney function.

5. The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula?

• A. Jitteriness
• B. Meconium ileus
• C. Excessive frothy saliva
• D. Increased need for sleep

Correct answer: C

Rationale: Excessive frothy saliva is a hallmark sign of tracheoesophageal fistula. The abnormal connection between the esophagus and trachea causes difficulty in swallowing, leading to an accumulation of saliva in the mouth. This symptom is crucial for early identification and management of tracheoesophageal fistula. Choices A, B, and D are incorrect as they are not specific indicators of tracheoesophageal fistula.

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