Nursing Elites

1. The nurse is caring for a 14-year-old adolescent who was admitted to the hospital after a suicide attempt. The adolescent’s mood appears stable, and the healthcare provider has recommended discharge. What is the nurse’s priority action?

• A. Ensure that a safety plan is in place before discharge
• B. Provide education about medication adherence
• C. Encourage the adolescent to participate in group therapy
• D. Schedule a follow-up appointment with a mental health professional

Correct answer: A

Rationale: The priority action for the nurse is to ensure that a safety plan is in place before discharge. A safety plan is essential to assist the adolescent in managing future crises and decreasing the likelihood of another suicide attempt. It provides guidance on coping strategies and resources to help the adolescent stay safe in times of distress.

2. When teaching parents of a 5-year-old child with sickle cell anemia about pain management, what information should be included?

• A. Apply cold compresses to painful areas.
• B. Encourage the child to rest as much as possible.
• C. Administer prescribed pain medication at the first sign of pain.
• D. Offer a high-protein diet to help with pain management.

Correct answer: C

Rationale: Administering prescribed pain medication at the first sign of pain is crucial in managing sickle cell anemia-related pain effectively. Prompt administration helps prevent the pain from escalating and becoming severe, enhancing the child's comfort and quality of life. Cold compresses, rest, and diet modifications may play supportive roles but are not as directly impactful in addressing acute pain episodes associated with sickle cell anemia. Therefore, while comforting measures like cold compresses and rest are helpful, they should not replace the importance of timely administration of prescribed pain medication. Additionally, offering a high-protein diet, although important for overall health, is not directly linked to managing acute pain in sickle cell anemia.

3. The parents of a 2-year-old child with a history of febrile seizures are being taught by the healthcare provider. Which statement by the parents indicates a need for further teaching?

• A. We should give our child acetaminophen when they have a fever.
• B. We should not place our child in a cool bath during a seizure.
• C. We should call 911 if the seizure lasts longer than 5 minutes.
• D. We should try to keep our child’s fever under control.

Correct answer: B

Rationale: Placing a child in a cool bath during a seizure is not recommended as it can be dangerous and may lead to accidental drowning or injuries. The priority during a febrile seizure is to ensure the safety of the child by placing them on a soft surface, removing any nearby objects that may cause harm, and gently turning their head to the side to prevent aspiration. Cooling measures like removing excess clothing can be employed, but immersing the child in a cool bath is not advised. Calling 911 if the seizure lasts longer than 5 minutes is important to seek immediate medical assistance. Administering acetaminophen to reduce fever and trying to keep the child's fever under control are appropriate interventions which should be continued.

4. A 10-year-old child is admitted to the hospital with a diagnosis of acute glomerulonephritis. The nurse notes that the child has edema and elevated blood pressure. What is the nurse’s priority action?

• A. Administer antihypertensive medication as prescribed
• B. Monitor the child’s urine output
• C. Elevate the child’s legs to reduce edema
• D. Restrict the child’s fluid intake

Correct answer: A

Rationale: In a child with acute glomerulonephritis presenting with edema and elevated blood pressure, the priority action for the nurse is to administer antihypertensive medication as prescribed. Managing blood pressure is essential to prevent further complications associated with the condition, such as worsening kidney function and cardiovascular strain. Monitoring urine output is important but not the priority over managing elevated blood pressure. Elevating the child's legs may help with edema but addressing the elevated blood pressure takes precedence. Fluid intake restriction may be necessary in some cases, but it is not the immediate priority when managing acute glomerulonephritis with edema and hypertension.

5. What suggestion should the nurse provide to prevent diaper rash in a 4-month-old infant as requested by the mother?

• A. Generously powder the baby's diaper area with talcum powder at each diaper change to promote dryness.
• B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
• C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
• D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.

Correct answer: C

Rationale: Using a barrier cream like zinc oxide forms a protective layer on the skin, creating a barrier against irritants and moisture, thus helping to prevent diaper rash. Unlike other options, barrier creams do not need to be completely removed at each diaper change, allowing the skin to remain protected between changes.

Similar Questions