Nursing Elites

1. The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed?

• A. "We will try to preserve the adopted child's racial heritage."
• B. "We are glad we will be getting full medical information when we adopt our child."
• C. "We will make sure to have everyone realize this is our child and a member of the family."
• D. "We understand strangers may make thoughtless comments about our child being different from us."

Correct answer: C

Rationale: The statement about making sure others realize the child is part of the family may indicate a focus on external validation rather than on the child’s needs and identity, suggesting a need for further teaching.

2. What is an important priority in dealing with the child suspected of having Wilms tumor?

• A. Intervening to minimize bleeding
• B. Monitoring temperature for infection
• C. Ensuring the abdomen is protected from palpation
• D. Teaching parents how to manage parenteral nutrition

Correct answer: C

Rationale: The correct priority in dealing with a child suspected of having Wilms tumor is ensuring the abdomen is protected from palpation. Palpating the abdomen could lead to tumor dissemination, which is crucial to prevent the spread of cancerous cells. Intervening to minimize bleeding, monitoring temperature for infection, and teaching parents how to manage parenteral nutrition are not the immediate priorities in suspected cases of Wilms tumor.

3. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

• A. Ask the parent when the neck was injured
• B. Refer for immediate medical evaluation
• C. Continue assessment to determine the cause of the neck pain
• D. Record head lag on the assessment record and continue the assessment of the child

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

4. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

• A. It is best to wait until the child asks about it.
• B. The best time to tell the child is between the ages of 7 and 10 years.
• C. It is not necessary to tell a child who was adopted so young.
• D. Telling the child is an important aspect of their parental responsibilities.

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

5. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

• A. Oliguria
• B. Weight loss
• C. Irritability and seizures
• D. Muscle weakness and cardiac dysrhythmias

Correct answer: C

Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.

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