Nursing Elites

1. The nurse is teaching parents guidelines for feeding their 8-month-old infant with failure to thrive (FTT). Which statement by the parents indicates a need for further teaching?

• A. We will continue to use the 24-kcal/oz formula.
• B. We will be sure to follow the formula preparation instructions.
• C. We will be sure to give our infant at least 8 oz of juice every day.
• D. We will be sure to feed our infant according to the written schedule.

Correct answer: C

Rationale: Providing 8 oz of juice daily is excessive for an 8-month-old infant and can displace other nutrient-rich foods or formulas that are necessary for growth, especially in an infant with FTT.

2. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

• A. Retake the temperature in 15 minutes after giving the Tylenol.
• B. Place a warm blanket on the child so chilling does not occur.
• C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
• D. Use cold compresses instead of Tylenol to control the fever.

Correct answer: C

Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.

3. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what?

• A. Cystic fibrosis
• B. Hyperthyroidism
• C. Congenital infection
• D. Breastfeeding problems

Correct answer: C

Rationale: FTT classified as defective utilization is often related to conditions like congenital infections, which interfere with the body's ability to effectively use nutrients. Conditions like cystic fibrosis and hyperthyroidism can also contribute to FTT but are categorized differently

4. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?

• A. The parent is trying to feed the child only what the child likes most
• B. Hispanics believe the evil eye enters when a person gets cold
• C. The parent is trying to restore normal balance through appropriate hot remedies
• D. Hispanics believe an innate energy called chi is strengthened by eating soup

Correct answer: C

Rationale: In Hispanic culture, the balance between hot and cold is important, and the parent may be giving the child broth to restore this balance while avoiding "cold" foods.

5. Which is usually the only symptom of pediculosis capitis (head lice)?

• A. Itching
• B. Vesicles
• C. Scalp rash
• D. Localized inflammatory response

Correct answer: A

Rationale: Itching is typically the primary and most common symptom of pediculosis capitis due to the lice bites on the scalp.

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