Nursing Elites

1. During a health assessment of a school-age child, where should the nurse focus more attention based on the child's developmental level?

• A. Infections
• B. Poisonings
• C. Risk-taking behaviors
• D. Accidents and injuries

Correct answer: D

Rationale: During the school-age period, children are active, curious, and engaged in various physical activities, making them more susceptible to accidents and injuries. This developmental stage is characterized by increased motor skills and exploration, leading to a higher risk of unintentional harm. While infections, poisonings, and risk-taking behaviors are also concerns for school-age children, focusing on preventing and addressing accidents and injuries is essential due to their heightened physical activity and curiosity.

2. When you attempt to assess a 22-year-old woman who has been sexually assaulted, and she orders you not to touch her, your most appropriate initial action should be to

• A. ask the patient to sign a release form
• B. ask a female EMT-B to attempt to assess the patient
• C. explain to the patient that she must be examined
• D. transport the patient without performing an assessment

Correct answer: B

Rationale: In cases of sexual assault, it is crucial to prioritize the patient's emotional and physical comfort. Asking a female EMT-B to attempt the assessment is the most appropriate initial action as it respects the patient's need for privacy and comfort. Asking the patient to sign a release form (Choice A) is not the immediate concern when the patient's well-being and comfort are at stake. Explaining to the patient that she must be examined (Choice C) disregards her autonomy and can worsen the trauma she is experiencing. Transporting the patient without performing an assessment (Choice D) neglects the necessary evaluation and potentially vital care that she may require.

3. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

• A. Administering an antiviral agent
• B. Clustering care to conserve energy
• C. Offering oral fluids to promote hydration
• D. Providing an antitussive agent when necessary

Correct answer: B

Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is to cluster care to conserve energy. Infants with RSV often have difficulty breathing and need to rest frequently. Clustering care involves grouping nursing interventions to allow for longer periods of rest between activities, which helps prevent exhaustion and conserve the infant's energy. Administering an antiviral agent is not the primary intervention for RSV, as it is a viral infection and antiviral agents are not typically used for RSV. Offering oral fluids is important for hydration but may not be the priority when the infant is struggling to breathe. Providing an antitussive agent should be done judiciously and under medical guidance, as suppressing the cough reflex can be detrimental in RSV cases where coughing helps clear airway secretions.

4. A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?

• A. Administering chemotherapy
• B. Preventing infection
• C. Monitoring for signs of bleeding
• D. Providing nutritional support

Correct answer: A

Rationale: The correct answer is A: Administering chemotherapy. In the care of a child with acute lymphoblastic leukemia (ALL), the priority nursing intervention is administering chemotherapy. Chemotherapy is the primary treatment for ALL and plays a crucial role in managing the disease. While preventing infection, monitoring for signs of bleeding, and providing nutritional support are important aspects of caring for a child with ALL, administering chemotherapy takes precedence as it directly targets the cancer cells and aims to induce remission.

5. A child with a diagnosis of nephrotic syndrome is under the care of a nurse. What is the priority nursing intervention?

• A. Administering diuretics
• B. Monitoring urine output
• C. Administering corticosteroids
• D. Restricting fluid intake

Correct answer: B

Rationale: The priority nursing intervention when caring for a child with nephrotic syndrome is to monitor urine output. This is essential to assess kidney function and evaluate the effectiveness of treatment. Administering diuretics (Choice A) may be a part of the treatment plan but should not be the priority over monitoring urine output. Administering corticosteroids (Choice C) is a common treatment for nephrotic syndrome, but monitoring urine output takes precedence. Restricting fluid intake (Choice D) may be necessary in some cases, but it is not the priority intervention compared to monitoring urine output.

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