Nursing Elites

1. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?

• A. Poor appetite
• B. Reduction of edema
• C. Restriction to bed rest
• D. Increased potassium intake

Correct answer: B

Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.

2. The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?

• A. Pedals tricycle without assistance
• B. Unscrews a bolt on a toy
• C. Falls when bending over to touch toes
• D. Builds a tower of 10 cubes

Correct answer: C

Rationale: The correct answer is C. Falling when bending over to touch toes could indicate a developmental delay or a balance issue that may need further assessment. Choices A, B, and D are typical developmental milestones for a 3-year-old child. Pedaling a tricycle without assistance, unscrewing a bolt on a toy, and building a tower of 10 cubes are all age-appropriate activities for a child of this age.

3. By what age does birth weight usually triple?

• A. 1 year
• B. 1 month
• C. 2 years
• D. 6 months

Correct answer: A

Rationale: The correct answer is A: 1 year. By the age of 1 year, a baby’s birth weight typically triples. This period allows for significant growth and development in infants. Choices B, C, and D are incorrect because birth weight does not usually triple by 1 month, 2 years, or 6 months of age, respectively.

4. The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure?

• A. "We will give you your shot when your mommy comes back."
• B. "I will wipe your skin with a magic wipe and then hold the needle like this and say one, two, three, go and give you your shot. Are you ready?"
• C. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker."
• D. "This is a magic sword that will give you your medicine and make you all better."

Correct answer: C

Rationale: The correct answer is C because it acknowledges the child's feelings, provides clear instructions, and offers comfort and rewards to help the child cope with the procedure. Choice A is not appropriate as it may create anxiety about the injection. Choice B uses the term 'magic,' which may confuse the child and lead to fear. Choice D introduces a fantasy element that may not be beneficial in preparing the child for the injection.

5. The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical manifestations should the nurse expect to observe?

• A. Pain is common.
• B. Weight loss is severe.
• C. All are correct.
• D. Diarrhea is moderate to severe.

Correct answer: C

Rationale: The correct answer is C because Crohn's disease commonly presents with pain, severe weight loss, and moderate to severe diarrhea in affected individuals. Therefore, all the manifestations listed are typically observed in patients with Crohn's disease. Choice A alone is not sufficient as weight loss and diarrhea are also prominent symptoms. Choice B is incorrect as it only mentions weight loss, omitting other common manifestations. Choice D is also incorrect as it does not cover the full range of expected clinical signs in Crohn's disease.

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