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. What should be the priority action when caring for a child with acute laryngotracheobronchitis?

• A. Initiate measures to reduce fever.
• B. Ensure delivery of humidified oxygen.
• C. Provide support to reduce apprehension.
• D. Continually assess the respiratory status.

Correct answer: D

Rationale: When caring for a child with acute laryngotracheobronchitis, the priority action should be to continually assess the respiratory status. This is crucial to detect early signs of respiratory distress, such as worsening stridor or increased work of breathing. Prompt intervention can prevent further deterioration of the child's condition. Initiating measures to reduce fever (Choice A) may be necessary but is not the priority in this situation. Ensuring delivery of humidified oxygen (Choice B) is important for maintaining oxygenation but should follow the assessment of respiratory status. Providing support to reduce apprehension (Choice C) is also important for the child's comfort but is not the priority over assessing and managing respiratory distress.

3. 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.

4. A healthcare provider is discussing the care of an infant with colic with the parents. What should the healthcare provider explain is the cause of colicky behavior?

• A. Inadequate peristalsis
• B. Paroxysmal abdominal pain
• C. An allergic response to certain proteins in milk
• D. A protective mechanism designed to eliminate foreign proteins

Correct answer: B

Rationale: Colicky behavior in infants is primarily characterized by paroxysmal abdominal pain, resulting in excessive crying and fussiness. The pain episodes are often unpredictable and can be distressing for both the infant and the parents. Inadequate peristalsis (Choice A) refers to weak or ineffective bowel movements and is not the typical cause of colic. While some infants may experience colic due to an allergic response to certain proteins in milk (Choice C), this is not the primary cause of colic behavior in all infants. Choice D, a protective mechanism designed to eliminate foreign proteins, is not a recognized cause of colic. Therefore, the correct explanation for the cause of colicky behavior in infants is paroxysmal abdominal pain.

5. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

• A. “Tell me about your daily routine.”
• B. “You look tired. Is everything alright?”
• C. “When was the last time the baby had a bottle?”
• D. “Oh, it looks like you two are having a bad day.”

Correct answer: A

Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.

Similar Questions