Nursing Elites

1. The nurse is assessing a 3-year-old African American child whose height and weight are at the 20th percentile on the growth chart. What should the nurse recognize?

• A. The data suggest the child requires nutritional intervention
• B. The NCHS charts are accurate for U.S. African American children
• C. A correction factor is used for nonwhite ethnic groups
• D. No assessment can be made until several measurements are plotted over time

Correct answer: B

Rationale: The NCHS growth charts serve as reference guides for all racial or ethnic groups, including African American children. The 20th percentile for height and weight does not indicate nutritional failure but provides a reference point for ongoing assessment. Choice A is incorrect because being at the 20th percentile does not automatically imply the need for nutritional intervention. Choice C is incorrect as there is no correction factor specifically used for nonwhite ethnic groups in this context. Choice D is incorrect as a single measurement at the 20th percentile can provide valuable information for assessment.

2. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

• A. Reassessments
• B. Nursing care provided
• C. Initial assessments
• D. All of the above

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

3. An eleven-year-old boy is admitted with a history of type 1 diabetes. What information about school age should the nurse use to formulate the teaching plan for daily injections?

• A. The parents do not need to learn the procedure.
• B. The child is old enough to give most of his injections.
• C. Self-injections will be possible when he is closer to adolescence.
• D. The child can learn about self-injections when he is able to reach all injection sites.

Correct answer: B

Rationale: By the age of eleven, many children are capable of administering their own insulin injections with supervision, fostering independence and better management of their diabetes. This age is appropriate for the child to take on more responsibility for their care. While parental involvement is still crucial for supervision and guidance, the child can start to learn and perform the injections themselves. Choice A is incorrect because parental involvement is important for safety and proper technique. Choice C is incorrect as waiting until closer to adolescence may delay the child's ability to manage their diabetes effectively. Choice D is incorrect as reaching injection sites is not the sole criteria; proper technique and supervision are essential.

4. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

• A. All below
• B. Considering alternative actions
• C. Using formal and informal thinking to gather data
• D. Giving deliberate thought to a patient's problem

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

5. What is the primary symptom of congenital diaphragmatic hernia in a newborn?

• A. Cyanosis
• B. Bradycardia
• C. Absent breath sounds
• D. Tachypnea

Correct answer: C

Rationale: Absent breath sounds on the affected side are a primary symptom of congenital diaphragmatic hernia. Cyanosis, bradycardia, and tachypnea may also be present but are not the primary symptom. Cyanosis is a bluish discoloration of the skin due to poor oxygenation, bradycardia is a slower than normal heart rate, and tachypnea is rapid breathing.

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