Nursing Elites

1. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?

• A. Deep-breathing exercises
• B. Upright positioning
• C. Coughing
• D. Chest percussion

Correct answer: B

Rationale: Upright positioning is the optimal intervention to promote maximum chest expansion in a child with Duchenne muscular dystrophy. By placing the child in an upright position, gravity can assist in expanding the chest cavity, facilitating better lung expansion and improving breathing efficiency. Deep-breathing exercises may be beneficial but are not as effective in maximizing chest expansion as upright positioning. Coughing and chest percussion focus more on airway clearance and are not directly aimed at promoting chest expansion.

2. Why might a healthcare provider question a health care provider's order for a tap water enema for a 6-month-old infant with suspected Hirschsprung disease?

• A. The result could lead to loss of necessary nutrients.
• B. It could cause a fluid and electrolyte imbalance.
• C. It could increase the fear of intrusive procedures.
• D. The result could cause shock from a sudden drop in temperature.

Correct answer: B

Rationale: The correct answer is B. Tap water enemas can cause significant fluid and electrolyte imbalances, particularly in infants, making them unsafe for this age group. Choice A is incorrect because tap water enemas are unlikely to lead to loss of necessary nutrients. Choice C is incorrect as it does not directly relate to the physiological risk of tap water enemas. Choice D is incorrect as shock from a sudden drop in temperature is not a common concern with tap water enemas.

3. A 2-year-old child is admitted to the hospital with a diagnosis of Kawasaki disease. What is the primary goal of therapy during the acute phase?

• A. Preventing coronary artery aneurysms
• B. Reducing fever
• C. Improving cardiac function
• D. Preventing dehydration

Correct answer: A

Rationale: The primary goal of therapy during the acute phase of Kawasaki disease is to prevent coronary artery aneurysms, which are a serious complication of this condition. Coronary artery aneurysms can lead to long-term cardiovascular issues, making prevention crucial. While reducing fever and improving cardiac function are important aspects of managing Kawasaki disease, the primary focus in the acute phase is on preventing coronary artery aneurysms. Dehydration prevention is also essential but not the primary goal during the acute phase of this disease.

4. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. What does the nurse expect when palpating the infant’s abdomen?

• A. A distended colon
• B. Marked tenderness around the umbilicus
• C. An olive-sized mass in the right upper quadrant
• D. Rhythmic peristaltic waves in the lower abdomen

Correct answer: C

Rationale: When palpating the abdomen of an infant with hypertrophic pyloric stenosis (HPS), the nurse would expect to feel an olive-sized mass in the right upper quadrant. This finding is characteristic of HPS due to the hypertrophied pylorus muscle. Choices A, B, and D are incorrect. A distended colon is not typically associated with HPS. Marked tenderness around the umbilicus is not a specific finding of HPS. Rhythmic peristaltic waves in the lower abdomen are not expected in HPS, as the condition primarily affects the pylorus region of the stomach.

5. A 2-year-old child who was admitted to the hospital for further surgical repair of a clubfoot is standing in the crib, crying. The child refuses to be comforted and calls for the mother. As the nurse approaches the crib to provide morning care, the child screams louder. Knowing that this behavior is typical of the stage of protest, what is the most appropriate nursing intervention?

• A. Use comforting measures while holding the child.
• B. Fill the basin with water and proceed to bathe the child.
• C. Sit by the crib and bathe the child later when the anxiety decreases.
• D. Postpone the bath for a day because a child this upset should not be traumatized further.

Correct answer: C

Rationale: During the stage of protest, children may exhibit distress and cling to familiar figures, resisting interactions with others. The most appropriate nursing intervention is to sit by the crib, offer comfort, and wait until the child's anxiety decreases before proceeding with bathing. This approach allows the child to feel supported and gradually transition to accepting care. Choice A is incorrect because forcing comfort may escalate the child's distress. Choice B is inappropriate as it disregards the child's emotional state and rushes into the bathing procedure. Choice D is not ideal as it suggests delaying care for an extended period, which may not address the child's immediate needs for comfort and hygiene.

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