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. A child with type 1 diabetes mellitus is being discharged from the hospital. What is important for the nurse to include in the discharge teaching?

• A. Monitor blood glucose levels once a day
• B. Follow a strict meal plan
• C. Administer insulin only when blood glucose is high
• D. Recognize signs of hypoglycemia

Correct answer: D

Rationale: Recognizing signs of hypoglycemia is essential for managing type 1 diabetes mellitus. Hypoglycemia, which occurs when blood glucose levels drop too low, can be dangerous and requires immediate intervention to prevent severe complications. Monitoring blood glucose levels more frequently than once a day, following a strict meal plan, and administering insulin only when blood glucose is high are important aspects of diabetes management but recognizing signs of hypoglycemia is crucial as it enables prompt action to prevent adverse outcomes.

3. A child with a diagnosis of celiac disease is admitted to the hospital. What dietary restriction should the nurse teach the parents?

• A. Avoid dairy products
• B. Avoid gluten
• C. Avoid high-fat foods
• D. Avoid foods high in sugar

Correct answer: B

Rationale: The correct answer is to 'Avoid gluten.' Celiac disease is an autoimmune disorder triggered by the consumption of gluten, a protein found in wheat, barley, and rye. When individuals with celiac disease ingest gluten, it causes an immune response that attacks the lining of the small intestine. Therefore, avoiding gluten is crucial in managing celiac disease to prevent symptoms and intestinal damage. Choices A, C, and D are incorrect because they do not address the specific dietary restriction necessary for individuals with celiac disease. While some individuals with celiac disease may also have lactose intolerance (not dairy allergy) or may need to manage fat or sugar intake for other health reasons, the primary dietary focus for celiac disease is the strict avoidance of gluten-containing foods.

4. A child with a diagnosis of appendicitis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

• A. Administering antibiotics
• B. Maintaining strict NPO status
• C. Encouraging fluid intake
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct preoperative intervention for a child with appendicitis scheduled for surgery is maintaining strict NPO (nothing by mouth) status. This is crucial to reduce the risk of aspiration during anesthesia induction and prevent potential complications during surgery. Administering antibiotics may be a part of the treatment plan but is not a preoperative intervention. Encouraging fluid intake is contraindicated preoperatively to avoid delays in surgery and complications related to anesthesia. Monitoring for signs of infection is important postoperatively to assess for any complications that may arise due to the surgical procedure.

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

• A. Administering antibiotics
• B. Isolating the child
• C. Monitoring vital signs
• D. Administering fluids

Correct answer: B

Rationale: The priority nursing intervention for a child admitted with bacterial meningitis is isolating the child. Isolation is crucial to prevent the spread of the highly contagious infection to other patients and healthcare workers. Administering antibiotics (Choice A) is important but isolating the child takes precedence to contain the spread of the infection. Monitoring vital signs (Choice C) and administering fluids (Choice D) are essential aspects of care but do not address the immediate need to prevent transmission of the infection.

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