Nursing Elites

1. The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her?

• A. Fluids in addition to breast milk are not needed.
• B. Water should be given if the infant seems to nurse longer than usual.
• C. Clear juices are better than water to promote adequate fluid intake.
• D. Water once or twice a day will make up for losses resulting from environmental temperature.

Correct answer: A

Rationale: Breast milk provides adequate hydration, even in warm weather, so additional fluids like water are not necessary and can interfere with breastfeeding.

2. A nurse is carrying on a conversation with a 7-year-old child during an office visit. Which is an example of the level of language development the nurse should expect in this child?

• A. Fascination with bathroom language
• B. Difficulty understanding the concept of 'half past' in reference to time
• C. Ability to carry on an adult conversation
• D. Inability to speak in full sentences

Correct answer: B

Rationale: The correct answer is B. Understanding time concepts like 'half past' can be challenging for a 7-year-old, indicating the level of language development. Choice A is incorrect as fascination with bathroom language is common in this age group but not necessarily indicative of language development. Choice C is incorrect as a 7-year-old typically cannot carry on an adult conversation due to cognitive and experiential limitations. Choice D is incorrect as by the age of 7, children should be able to speak in full sentences.

3. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?

• A. Encourage the child to blow the nose gently
• B. Notify the physician if mucus is observed in the emesis
• C. Position the child supine in the immediate postoperative period
• D. Avoid giving citrus juice

Correct answer: D

Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.

4. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

• A. Metabolic acidosis
• B. Respiratory alkalosis
• C. Metabolic and respiratory acidosis
• D. Metabolic and respiratory alkalosis

Correct answer: D

Rationale: Both metabolic and respiratory alkalosis can cause overexcitability and nervous system stimulation due to a decrease in ionized calcium levels, which can cause symptoms such as tetany and paresthesias. Acidosis typically has the opposite effect, leading to depression of the nervous system.

5. The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism should the nurse include when responding to the mother?

• A. Repression
• B. Regression
• C. Rationalization
• D. Fantasy

Correct answer: B

Rationale: The correct answer is B: Regression. Regression is a common defense mechanism where a child reverts to an earlier stage of development, such as thumb-sucking, to cope with stress. In this scenario, the 6-year-old boy is using thumb-sucking (a behavior typical of earlier developmental stages) as a way to deal with the stress of surgery. Repression (choice A) involves unconsciously blocking out thoughts or feelings, which is not applicable in this case. Rationalization (choice C) is a defense mechanism where illogical or unreasonable explanations are provided to justify behavior, which is not relevant here. Fantasy (choice D) refers to the use of imagination to escape from reality, which is also not the appropriate defense mechanism for the situation described.

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