Nursing Elites

1. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission, but while waiting for the administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?

• A. notify the practitioner
• B. measure abdominal girth
• C. auscultate for bowel sounds
• D. take vital signs, including blood pressure

Correct answer: A

Rationale: The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. This change in the patient's condition is significant, requiring prompt notification of the practitioner for further evaluation and management. While measuring abdominal girth (Choice B) is important for assessing abdominal distention, it is not the priority when a potential spontaneous reduction may have occurred. Auscultating for bowel sounds (Choice C) and taking vital signs, including blood pressure (Choice D), are routine nursing assessments but do not address the immediate need to inform the practitioner of a possible change in the patient's condition that necessitates urgent attention.

2. The caregiver explains to the parent of a 2-year-old child that the toddler’s negativism is expected at this age. What need is this behavior meeting?

• A. Trust
• B. Attention
• C. Discipline
• D. Independence

Correct answer: D

Rationale: Negativism in toddlers is a common behavior at this age as they begin to assert their independence and show a desire to control their environment. Choice A, 'Trust,' does not align with the behavior of negativism, as it is more about the child's growing autonomy. Choice B, 'Attention,' while important for child development, is not the primary need being met by negativism in this context. Choice C, 'Discipline,' though important in guiding behavior, is not the underlying need being expressed through negativism. Therefore, the correct answer is D, 'Independence,' as toddlers exhibit negativism as a way to assert their independence and autonomy.

3. .The parents of a 6-week-old infant who was born without an immune system ask a nurse why their baby is still so healthy. How should the nurse reply?

• A. Exposure to pathogens during this time can be limited.
• B. Some antibodies are produced by the infant’s colonic bacteria.
• C. Antibodies are passively received from the mother through the placenta and breast milk.
• D. Fewer antibodies are produced by the fetal thymus during the eighth and ninth months of gestation.

Correct answer: C

Rationale: Infants receive passive immunity through antibodies from the mother during pregnancy and breastfeeding, which protect them initially.

4. The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?

• A. infection
• B. hypertension
• C. encephalopathy
• D. edema

Correct answer: A

Rationale: Monitoring the temperature of a child with minimal change nephrotic syndrome is crucial to detect early signs of infection. Infection is a common complication in nephrotic syndrome, and fever can be an early indicator. Hypertension (choice B) is not typically associated with nephrotic syndrome. Encephalopathy (choice C) is a neurological complication and would present with altered mental status rather than a change in temperature. Edema (choice D) is a common symptom of nephrotic syndrome but is not typically monitored through temperature assessment.

5. A 3-year-old child ingests a substance that may be a poison. The parent calls a neighbor who is a nurse and asks what to do. What should the nurse recommend the parent to do?

• A. Administer syrup of ipecac.
• B. Call the poison control center.
• C. Take the child to the emergency department.
• D. Give the child bread dipped in milk to absorb the poison.

Correct answer: B

Rationale: In cases of potential poisoning, immediate guidance from professionals is crucial. Administering syrup of ipecac is no longer recommended routinely due to potential risks and lack of benefit. Taking the child to the emergency department is necessary in severe cases but may not always be the immediate action needed. Giving the child bread dipped in milk is not an appropriate method to manage poisoning and could potentially worsen the situation. Therefore, the most appropriate action for the nurse to recommend is to call the poison control center for expert advice on managing the situation.

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