Nursing Elites

1. In planning care for a 7-year-old boy with diabetes insipidus, what is the priority nursing diagnosis?

• A. Deficient fluid volume related to dehydration
• B. Excess fluid volume related to edema
• C. Deficient knowledge related to fluid intake regimen
• D. Imbalanced nutrition, more than body requirements related to excess weight

Correct answer: A

Rationale: The priority nursing diagnosis for a 7-year-old boy with diabetes insipidus is deficient fluid volume related to dehydration. Diabetes insipidus leads to excessive urination and fluid loss, which can result in dehydration. This diagnosis should take precedence as restoring fluid balance is crucial in managing this condition. Choices B, C, and D are less of a priority in this case. Excess fluid volume related to edema is not typically associated with diabetes insipidus. Deficient knowledge about fluid intake and imbalanced nutrition related to excess weight may be important but addressing the dehydration and fluid volume deficit is the most critical aspect in the immediate care of a child with diabetes insipidus.

2. What finding would lead the nurse to suspect that a child has Turner syndrome?

• A. Webbed neck
• B. Microcephaly
• C. Gynecomastia
• D. Cognitive delay

Correct answer: A

Rationale: A webbed neck is a key feature seen in Turner syndrome, a genetic condition that occurs in females due to a complete or partial absence of one of the X chromosomes. This physical trait is caused by excess skin on the neck, giving it a webbed appearance. Microcephaly (Choice B) is a condition characterized by a smaller than average head size and is not typically associated with Turner syndrome. Gynecomastia (Choice C) refers to breast enlargement in males and is not a common finding in Turner syndrome, which affects females. Cognitive delay (Choice D) is not a specific characteristic of Turner syndrome, as the syndrome primarily affects physical development and may not necessarily impact cognitive abilities.

3. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?

• A. Pertussis, tetanus, polio, and measles
• B. Diphtheria, pertussis, tetanus, and polio
• C. Rubella, polio, tuberculosis, and pertussis
• D. Measles, mumps, rubella, and tuberculosis

Correct answer: B

Rationale: By 11 months of age, the recommended vaccines for infants include diphtheria, pertussis, tetanus, and polio. These vaccines are part of the routine immunization schedule to protect infants from serious infectious diseases. Choice A is incorrect because measles is not typically administered at this age. Choice C is incorrect because rubella and tuberculosis are not part of routine infant immunizations. Choice D is incorrect because measles, mumps, and rubella are usually given as a combination vaccine later in childhood, not at 11 months of age.

4. A parent tearfully tells a nurse, 'They think our child is developmentally delayed. We are thinking about investigating a preschool program for cognitively impaired children.' What is the nurse’s most appropriate response?

• A. Praise the parent for the decision and encourage the plan.
• B. Ask for more specific information related to the developmental delays.
• C. Advise the parent to have the healthcare provider help choose an appropriate program.
• D. Explain that this may be a premature action and the developmental delays could disappear.

Correct answer: B

Rationale: The most appropriate response in this situation is to ask for more specific information related to the developmental delays. By seeking additional details, the nurse can better understand the child's needs and provide tailored guidance and support to the parent. Praising the parent (Choice A) before fully grasping the situation may not be beneficial. Advising the parent to involve the healthcare provider in selecting a program (Choice C) is premature without a comprehensive understanding of the child's developmental delays. Explaining that the delays might resolve on their own (Choice D) is inappropriate as it dismisses the parent's concerns and the necessity for timely and appropriate interventions.

5. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

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