Nursing Elites

1. The mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex is being taught by the nurse. Which response from his mother indicates a need for further teaching?

• A. He needs to wear a medical alert identification.
• B. I will need to inform his caregivers about this.
• C. A product's label always indicates if it is latex-free.
• D. He should avoid all contact with latex.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because not all products are clearly labeled as latex-free. It is essential for the mother to understand that she should not solely rely on product labels to determine latex content. She should be encouraged to verify with manufacturers and consult healthcare providers for accurate information. Choices A, B, and D are correct responses. Wearing a medical alert identification, informing caregivers, and ensuring the boy avoids all contact with latex are crucial steps in managing his sensitivity to latex and preventing potential allergic reactions.

2. A nurse is reviewing the laboratory report of a child with tetralogy of Fallot that indicates an elevated RBC count. What does the nurse identify as the cause of the polycythemia?

• A. Low tissue oxygen needs
• B. Tissue oxygen needs
• C. Diminished iron levels
• D. Hypertrophic cardiac muscle

Correct answer: B

Rationale: The correct answer is B: Tissue oxygen needs. Polycythemia occurs in response to chronic hypoxia, leading the body to increase red blood cell production to enhance oxygen delivery. In tetralogy of Fallot, a congenital heart defect that results in reduced oxygen levels in the blood, the body compensates by producing more red blood cells. Choice A is incorrect as low tissue oxygen needs would not trigger polycythemia. Choice C, diminished iron levels, is not the cause of polycythemia in this case. Choice D, hypertrophic cardiac muscle, is unrelated to the pathophysiology of polycythemia in tetralogy of Fallot.

3. A nurse on the pediatric unit is observing the developmental skills of several 2-year-old children in the playroom. Which child should the nurse continue to evaluate?

• A. Cannot stand on one foot
• B. Builds a tower of 7 blocks
• C. Uses echolalia when speaking
• D. Colors outside the lines of a picture

Correct answer: C

Rationale: The correct answer is C. Using echolalia, which is the repetition of words or phrases, is not typical for a 2-year-old child and may indicate the need for further evaluation. Choices A, B, and D are all within the expected developmental skills for a 2-year-old. While most 2-year-olds may not be able to stand on one foot, it is not a cause for concern at this age. Building a tower of 7 blocks and coloring outside the lines of a picture are both appropriate for a 2-year-old's developmental skills.

4. Upon assessing a newborn immediately after delivery, you note that the infant is breathing spontaneously and has a heart rate of 90 beats/min. What is the most appropriate initial management for this newborn?

• A. begin positive pressure ventilations
• B. provide blow-by oxygen with oxygen tubing
• C. assess the newborn's skin condition and color
• D. start chest compressions and contact medical control

Correct answer: A

Rationale: A heart rate below 100 beats/min in a newborn indicates the need for positive pressure ventilation to improve oxygenation. Providing positive pressure ventilations helps in assisting the newborn's breathing efforts to ensure adequate oxygenation. Choice B, providing blow-by oxygen, may not be sufficient to address the underlying issue of inadequate breathing. Choice C, assessing the newborn's skin condition and color, is important but not the most immediate action needed for a heart rate below 100 beats/min. Choice D, starting chest compressions, is not indicated as the infant is breathing spontaneously and has a heart rate, albeit lower than normal, which does not warrant chest compressions.

5. In planning care for a 7-year-old boy with diabetes insipidus, what is the priority nursing diagnosis?

• A. Deficient fluid volume related to dehydration
• B. Excess fluid volume related to edema
• C. Deficient knowledge related to fluid intake regimen
• D. Imbalanced nutrition, more than body requirements related to excess weight

Correct answer: A

Rationale: The priority nursing diagnosis for a 7-year-old boy with diabetes insipidus is deficient fluid volume related to dehydration. Diabetes insipidus leads to excessive urination and fluid loss, which can result in dehydration. This diagnosis should take precedence as restoring fluid balance is crucial in managing this condition. Choices B, C, and D are less of a priority in this case. Excess fluid volume related to edema is not typically associated with diabetes insipidus. Deficient knowledge about fluid intake and imbalanced nutrition related to excess weight may be important but addressing the dehydration and fluid volume deficit is the most critical aspect in the immediate care of a child with diabetes insipidus.

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