Nursing Elites

1. The nurse is assisting low-income families to access health care. The nurse is aware that, in today's society, this most accurately defines the diversity of a modern family.

• A. A family consists of parents and their offspring living together.
• B. A family is whatever the child and family say it is.
• C. A family is two or more people related or unrelated who are living together.
• D. A family is two or more genetically related persons living together with separate roles.

Correct answer: B

Rationale: Given the diversity of families in today's society, some believe that family should be defined as whatever the child and family say it is.

2. A 5-year-old child with a diagnosis of asthma is being evaluated for medication management. What is an important assessment for the nurse to perform?

• A. Assess the child's sleep patterns
• B. Assess the child's dietary intake
• C. Assess the child's academic performance
• D. Assess the child's behavior at home

Correct answer: B

Rationale: Assessing the child's dietary intake is crucial in managing asthma as certain foods can trigger symptoms or exacerbate the condition. Monitoring the child's diet can help identify triggers, ensure proper nutrition, and support the child's overall health. Assessing sleep patterns (Choice A) may be relevant but is not as directly linked to asthma management as dietary intake. Academic performance (Choice C) and behavior at home (Choice D) are important aspects of a child's well-being but are not directly related to asthma management.

3. A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?

• A. Monitoring fluid and electrolyte balance
• B. Encouraging regular exercise
• C. Administering antipyretics
• D. Administering antibiotics

Correct answer: A

Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract, leading to fluid loss. Maintaining fluid and electrolyte balance is essential in managing gastroenteritis to prevent dehydration and electrolyte imbalances. Encouraging regular exercise (Choice B) is not a priority in the acute phase of gastroenteritis when the focus is on rehydration and symptom management. Administering antipyretics (Choice C) may be considered for fever management but is not the priority over monitoring fluid and electrolyte balance. Administering antibiotics (Choice D) is not routinely indicated for viral gastroenteritis, which is a common cause of the condition in children.

4. A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should alert the nurse to perform a further assessment?

• A. Flat occiput
• B. Small, low-set ears
• C. Circumoral cyanosis
• D. Protruding furrowed tongue

Correct answer: C

Rationale: Circumoral cyanosis should alert the nurse to perform a further assessment because it may indicate inadequate oxygenation or circulation, potentially related to cardiac or respiratory issues. Flat occiput (choice A) is a common finding in infants and is not typically concerning. Small, low-set ears (choice B) are common in Down syndrome and not specifically indicative of an acute issue requiring immediate further assessment. Protruding furrowed tongue (choice D) is also commonly seen in infants with Down syndrome and typically does not warrant immediate further assessment unless associated with other concerning signs or symptoms.

5. Which of the following parameters would be LEAST reliable when assessing the perfusion status of a 2-year-old child with possible shock?

• A. distal capillary refill
• B. systolic blood pressure
• C. skin color and temperature
• D. presence of peripheral pulses

Correct answer: B

Rationale: Systolic blood pressure is the least reliable parameter when assessing the perfusion status of a 2-year-old child with possible shock. In pediatric patients, especially young children, blood pressure may not decrease until significant shock has already occurred, making it a late indicator of inadequate perfusion. Depending solely on systolic blood pressure to evaluate perfusion status in this age group can lead to a delay in appropriate interventions. Distal capillary refill time, skin color, and temperature changes, and the presence of peripheral pulses are more sensitive and early indicators of perfusion status in pediatric patients. Monitoring distal capillary refill provides information on peripheral perfusion, while changes in skin color and temperature can signal circulatory compromise. Evaluating the presence or absence of peripheral pulses offers insights into vascular perfusion. These parameters offer more reliable and prompt feedback on a child's perfusion status compared to systolic blood pressure.

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