Nursing Elites

1. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

• A. All below
• B. Oliguria
• C. Confusion
• D. Pale extremities

Correct answer: A

Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.

2. A child has a planned hospitalization in a few weeks, and the client and family appear very stressed. Which nursing action will minimize their stress?

• A. Telling the client and family that everything will be fine
• B. Explaining how the child will benefit from the surgery
• C. Telling the client and family that the surgeon is very good
• D. Giving a tour of the hospital unit or surgical area

Correct answer: D

Rationale: The correct nursing action to minimize the stress of the child and family is giving a tour of the hospital unit or surgical area. Familiarizing them with the hospital environment can help reduce their anxiety by allowing them to see where the child will be staying and the surroundings. Choices A, B, and C do not directly address the need to reduce stress by providing a tangible way to alleviate anxiety through exposure to the hospital setting.

3. An eleven-year-old boy is admitted with a history of type 1 diabetes. What information about school age should the nurse use to formulate the teaching plan for daily injections?

• A. The parents do not need to learn the procedure.
• B. The child is old enough to give most of his injections.
• C. Self-injections will be possible when he is closer to adolescence.
• D. The child can learn about self-injections when he is able to reach all injection sites.

Correct answer: B

Rationale: By the age of eleven, many children are capable of administering their own insulin injections with supervision, fostering independence and better management of their diabetes. This age is appropriate for the child to take on more responsibility for their care. While parental involvement is still crucial for supervision and guidance, the child can start to learn and perform the injections themselves. Choice A is incorrect because parental involvement is important for safety and proper technique. Choice C is incorrect as waiting until closer to adolescence may delay the child's ability to manage their diabetes effectively. Choice D is incorrect as reaching injection sites is not the sole criteria; proper technique and supervision are essential.

4. Which type of play would be most beneficial for preparing a preschool-age child for upcoming surgery to reduce the stress of the event?

• A. Cooperative play
• B. Associative play
• C. Dramatic play
• D. Onlooker play

Correct answer: C

Rationale: Dramatic play involves role-playing, allowing children to act out scenarios and become more comfortable with them. This type of play can help reduce anxiety about upcoming events like surgery. Cooperative play involves working together towards a common goal, associative play involves loosely interacting with others, and onlooker play involves observing others play without actively participating. These types of play are not as directly related to preparing a child for surgery and reducing stress as dramatic play.

5. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?

• A. The child has recently been exposed to an infectious disease
• B. The child has symptoms of a cold but no fever
• C. The child is having intermittent episodes of diarrhea
• D. The child has a disorder that causes a deficient immune system

Correct answer: D

Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.

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