Nursing Elites

1. The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity due to the cast and its location.
• B. Deficient knowledge related to cast care.
• C. Risk for delayed development related to immobility.
• D. Self-care deficit related to immobility.

Correct answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity due to the cast and its location. When a child has a long-leg hip spica cast, the priority nursing diagnosis is to prevent impaired skin integrity. This is because the child's mobility is restricted, and pressure from the cast can lead to skin breakdown. Option B is incorrect as while education is essential, it is not the priority when skin integrity is at risk. Option C is incorrect because while immobility can impact development, immediate skin integrity concerns take precedence. Option D is incorrect as self-care deficit, while important, is secondary to preventing skin breakdown in this scenario.

2. The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?

• A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
• B. Deficient knowledge related to the presence of a genetic disorder
• C. Delayed growth and development related to a cognitive impairment
• D. Impaired physical mobility related to poor muscle tone

Correct answer: A

Rationale: The priority nursing diagnosis for a 3-day-old girl with Down syndrome, whose mother had no prenatal care, is imbalanced nutrition, less than body requirements related to the effects of hypotonia. Newborns with Down syndrome often experience feeding difficulties due to hypotonia, which can lead to inadequate nutrition intake. Option B is incorrect because at this age, the infant is not capable of having knowledge deficits related to a genetic disorder. Option C is incorrect as delayed growth and development are not the immediate priority in this scenario. Option D is incorrect as impaired physical mobility is not typically a priority concern for a newborn with Down syndrome.

3. A healthcare professional is assessing a child with suspected bacterial meningitis. What is a common clinical manifestation that the healthcare professional is likely to observe?

• A. Rash
• B. Photophobia
• C. Jaundice
• D. Kernig sign

Correct answer: D

Rationale: A common clinical manifestation of bacterial meningitis is a positive Kernig sign, indicating irritation of the meninges. Rash (Choice A) is not typically associated with bacterial meningitis. Photophobia (Choice B) can be present but is more commonly seen in viral meningitis. Jaundice (Choice C) is not a typical clinical manifestation of meningitis and is more indicative of liver dysfunction.

4. When caring for a child diagnosed with cystic fibrosis, what is the priority nursing intervention?

• A. Administering pancreatic enzymes
• B. Providing respiratory therapy
• C. Encouraging physical activity
• D. Encouraging frequent handwashing

Correct answer: A

Rationale: The priority nursing intervention when caring for a child with cystic fibrosis is administering pancreatic enzymes. Cystic fibrosis is a genetic disorder that affects the digestive and respiratory systems. Administering pancreatic enzymes is crucial in aiding digestion as patients with cystic fibrosis often have pancreatic insufficiency. While providing respiratory therapy and encouraging physical activity are important aspects of care for individuals with cystic fibrosis, administering pancreatic enzymes takes precedence in addressing the malabsorption issues associated with the condition. Encouraging frequent handwashing is also essential in infection control, but it is not the priority intervention specifically related to managing cystic fibrosis.

5. A 4-year-old child is admitted to the hospital with a diagnosis of epiglottitis. What is the priority nursing intervention?

• A. Administer antibiotics
• B. Provide humidified oxygen
• C. Keep the child NPO
• D. Position the child upright

Correct answer: C

Rationale: The priority nursing intervention for a 4-year-old child admitted with epiglottitis is to keep the child NPO (nothing by mouth). This is crucial to prevent further airway compromise due to the inflamed epiglottis. Administering antibiotics may be necessary but is not the priority at this moment. Providing humidified oxygen can support oxygenation but does not address the immediate risk of airway obstruction. Positioning the child upright may help with breathing but does not address the risk of aspiration. Keeping the child NPO is essential to maintain a patent airway and prevent complications associated with epiglottitis.

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