Nursing Elites

1. A 1-month-old girl with low-set ears and severe hypotonia has been diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?

• A. Interrupted family process related to the child's diagnosis
• B. Deficient knowledge related to the genetic disorder
• C. Grieving related to the child's poor prognosis
• D. Ineffective coping related to the stress of providing care

Correct answer: C

Rationale: The most likely nursing diagnosis for a 1-month-old girl with trisomy 18, characterized by low-set ears and severe hypotonia, is 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience grief as they come to terms with the challenges and uncertainties associated with the condition. 'Interrupted family process' may not be as relevant since the primary focus is on the child's condition. 'Deficient knowledge related to the genetic disorder' could be important but may not be the most likely initial concern, as emotional support for the family is crucial at this point. 'Ineffective coping related to the stress of providing care' is a broad diagnosis that does not specifically address the emotional response to the child's prognosis, which is the primary concern in this case.

2. A group of students is reviewing information about the endocrine system in infants and children. The students demonstrate understanding of the information when they state:

• A. Endocrine glands begin developing during gestation.
• B. Endocrine glands are fully functional at birth.
• C. Infants may have difficulty regulating glucose and electrolytes.
• D. A child’s endocrine system plays a significant role in growth and development.

Correct answer: C

Rationale: The correct answer is C. Infants may have difficulty regulating glucose and electrolytes due to their immature endocrine systems. This can lead to issues such as hypoglycemia and electrolyte imbalances. Choice A is incorrect because endocrine glands actually begin developing early in gestation, not just in the third trimester. Choice B is incorrect as endocrine glands are not fully functional at birth; they continue to mature and develop after birth. Choice D is incorrect as a child's endocrine system has a significant impact on growth and development through the secretion of hormones that regulate various processes in the body, but it does not specifically address the difficulty in regulating glucose and electrolytes seen in infants.

3. A school nurse is teaching parents of school-age children about the importance of immunizations for childhood communicable diseases. What preventable disease may cause the complication of encephalitis?

• A. Varicella
• B. Scarlet fever
• C. Poliomyelitis
• D. Whooping cough

Correct answer: A

Rationale: The correct answer is Varicella (chickenpox), choice A. Varicella can lead to the complication of encephalitis, which is the inflammation of the brain. Scarlet fever (choice B) is caused by Group A Streptococcus bacteria and does not typically lead to encephalitis. Poliomyelitis (choice C) is a viral infection that affects the nervous system but does not directly cause encephalitis. Whooping cough (choice D), also known as pertussis, primarily affects the respiratory system and does not commonly result in encephalitis.

4. What is the priority nursing intervention for a child with a diagnosis of acute lymphoblastic leukemia (ALL) receiving chemotherapy?

• A. Preventing infection
• B. Administering chemotherapy
• C. Providing nutritional support
• D. Monitoring fluid intake

Correct answer: A

Rationale: The correct answer is A: Preventing infection. When caring for a child with acute lymphoblastic leukemia (ALL) undergoing chemotherapy, the top priority is to prevent infection. Chemotherapy suppresses the immune system, making the child more susceptible to infections. By implementing infection control measures such as hand hygiene, aseptic techniques, and environmental cleanliness, the nurse can help protect the child from potentially life-threatening infections. Administering chemotherapy (choice B) is important but not the priority over preventing infection. Providing nutritional support (choice C) and monitoring fluid intake (choice D) are essential aspects of care but take a back seat to preventing infection in this scenario.

5. The caregiver is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching?

• A. We will leave fireworks displays to the professionals.
• B. I will set our water heater at 130 degrees.
• C. All sleepwear should be flame retardant.
• D. The handles of pots on the stove should face inward.

Correct answer: B

Rationale: The correct answer is B. Setting the water heater at 130 degrees is incorrect because water heaters should be set to no higher than 120 degrees to prevent scald burns. Choice A is correct as leaving fireworks displays to professionals reduces the risk of burns. Choice C is also correct as flame-retardant sleepwear reduces the risk of burn injuries. Choice D is correct as keeping pot handles facing inward prevents accidental spills and burns.

Similar Questions