Nursing Elites

1. The nurse is teaching a parent with a 2-month-old infant who has been diagnosed with colic about ways to relieve colic. Which statement by the parent indicates the need for additional teaching?

• A. I should let my infant cry for at least 30 minutes before I respond.
• B. I will swaddle my infant tightly with a soft blanket.
• C. I should massage my infant's abdomen whenever possible.
• D. I will place my infant in an upright seat after feeding.

Correct answer: A

Rationale: Letting an infant cry for prolonged periods can exacerbate colic and increase the infant's distress. It is better to respond promptly to soothe the baby. Other methods like swaddling, gentle massage, and keeping the infant upright can help relieve colic symptoms.

2. The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment?

• A. A white reflex
• B. Blue-tinged sclerae
• C. A red reflex
• D. Yellow-tinged sclerae

Correct answer: A

Rationale: The correct answer is A: A white reflex. The 'white reflex' or leukocoria is a common sign of retinoblastoma. It occurs when the light reflects off the tumor in the eye, giving the pupil a white appearance instead of the normal red reflex. Blue-tinged sclerae (choice B) and yellow-tinged sclerae (choice D) are not typical manifestations of retinoblastoma. A red reflex (choice C) is the normal reflection seen in the eye when light is shone on it and is not associated with retinoblastoma.

3. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?

• A. Check the urine to see if hematuria has increased.
• B. Obtain the child's blood pressure and notify the healthcare provider.
• C. Obtain serum electrolytes and send urinalysis to the laboratory.
• D. Reassure the child and encourage bed rest until the headache improves.

Correct answer: B

Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.

4. Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?

• A. Babinski
• B. Moro
• C. Sucking
• D. Rooting

Correct answer: A

Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.

5. What is the most common cause of abdominal pain in school-aged children?

• A. Gastroenteritis
• B. Constipation
• C. Appendicitis
• D. Irritable bowel syndrome

Correct answer: B

Rationale: Constipation is the most common cause of abdominal pain in school-aged children. It is often due to dietary factors such as low fiber intake or insufficient fluid consumption. Chronic constipation can lead to complications like fecal impaction and soiling, highlighting the importance of early recognition and treatment. Gastroenteritis, although common, typically presents with diarrhea and vomiting. Appendicitis is more common in adolescents and typically presents with right lower quadrant pain. Irritable bowel syndrome is less common in children and is characterized by recurrent abdominal pain associated with defecation.

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