Nursing Elites

1. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?

• A. Request a detailed listing of symptoms.
• B. Ask the adolescent, "Why did you come here today?"
• C. Interview the parent away from the adolescent to determine the chief complaint
• D. Use what the adolescent says to determine, in correct medical terminology, what the problem is

Correct answer: B

Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.

2. What is an important priority in dealing with the child suspected of having Wilms tumor?

• A. Intervening to minimize bleeding
• B. Monitoring temperature for infection
• C. Ensuring the abdomen is protected from palpation
• D. Teaching parents how to manage parenteral nutrition

Correct answer: C

Rationale: The correct priority in dealing with a child suspected of having Wilms tumor is ensuring the abdomen is protected from palpation. Palpating the abdomen could lead to tumor dissemination, which is crucial to prevent the spread of cancerous cells. Intervening to minimize bleeding, monitoring temperature for infection, and teaching parents how to manage parenteral nutrition are not the immediate priorities in suspected cases of Wilms tumor.

3. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?

• A. Gently tap over the site.
• B. Apply a cold compress to the site.
• C. Raise the extremity above the level of the body
• D. Use a rubber band as a tourniquet for 5 minutes.

Correct answer: A

Rationale: Gently tapping over the site helps dilate the veins and increase visibility. Applying a cold compress or raising the extremity above the body level constricts the veins, making them harder to access. Prolonged tourniquet use can cause discomfort and venous congestion.

4. What is a common sign of moderate dehydration in children?

• A. Dry mucous membranes
• B. Normal capillary refill
• C. Hyperactive bowel sounds
• D. Edema

Correct answer: A

Rationale: Dry mucous membranes are a common sign of moderate dehydration in children, indicating a loss of bodily fluids. When a child is moderately dehydrated, the mucous membranes in the mouth and nose may appear dry. This condition can occur due to various factors such as vomiting, diarrhea, or inadequate fluid intake. Normal capillary refill (choice B) is not typically associated with dehydration; it is a measure of circulatory status. Hyperactive bowel sounds (choice C) can be present in conditions like gastroenteritis but are not specific to dehydration. Edema (choice D) is the retention of fluid in the body and is not a typical sign of dehydration.

5. What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age?

• A. Give large push-pull toys for kinetic stimulation
• B. Place a cradle gym across the crib to help develop fine motor skills
• C. Provide the child with finger paints to enhance fine motor skills
• D. Provide a stick horse to develop gross motor coordination

Correct answer: A

Rationale: Large push-pull toys are suitable for a 12-month-old as they encourage gross motor skills and physical activity, which are crucial for their development at this age.

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