Nursing Elites

1. When observing a distraught mother scolding her 3-year-old son for wetting his pants in the hallway of a pediatric unit, what initial action should the nurse take?

• A. Suggest that the mother consult a pediatric nephrologist.
• B. Provide disposable training pants while calming the mother.
• C. Refer the mother to a community parent education program.
• D. Inform the mother that toilet training is slower for boys.

Correct answer: B

Rationale: In this situation, the nurse's initial action should be to provide disposable training pants to manage the immediate issue of wetting while also calming the mother. This approach addresses the current distressing situation and offers a practical solution to alleviate the mother's concerns.

2. What should the nurse do first for a 6-year-old with asthma showing a prolonged expiratory phase, wheezing, and 35% of personal best peak expiratory flow rate (PEFR)?

• A. Administer a prescribed bronchodilator.
• B. Encourage the child to cough and take deep breaths.
• C. Report the findings to the healthcare provider.
• D. Identify the triggers that precipitated this attack.

Correct answer: A

Rationale: Administering a bronchodilator is the priority action in managing an acute asthma exacerbation in a child. Bronchodilators help to relax the muscles around the airways, opening them up and improving breathing. This intervention aims to address the immediate breathing difficulty and should be done promptly to provide relief for the child. Encouraging coughing and deep breaths (choice B) may worsen the child's condition by further constricting the airways. Reporting findings to the healthcare provider (choice C) is important but not the immediate priority in this acute situation. Identifying triggers (choice D) is crucial for long-term asthma management but is not the first step when managing an acute exacerbation.

3. What is the best response for a two-year-old boy who begins to cry when the mother starts to leave?

• A. Let's wave bye-bye to mommy.
• B. Two-year-olds usually stop crying the minute the parent leaves.
• C. Now be a big boy. Mommy will be back soon.
• D. Let's wave bye-bye to mommy.

Correct answer: D

Rationale: The best response for a two-year-old boy who begins to cry when the mother starts to leave is to wave bye-bye to mommy. This action helps the child understand that the separation is temporary and gives him a sense of closure. Choice A is the correct answer. Choice B is incorrect as it generalizes the behavior of two-year-olds. Choice C may invalidate the child's feelings by telling him to 'be a big boy' instead of acknowledging his emotions and providing comfort.

4. What age-appropriate play activity should the practical nurse suggest to the parents of a 7-month-old infant to encourage visual stimulation?

• A. Play peek-a-boo.
• B. Play pat-a-cake.
• C. Imitate animal sounds.
• D. Show how to clap hands.

Correct answer: A

Rationale: The practical nurse should suggest playing peek-a-boo to the parents of a 7-month-old infant to encourage visual stimulation. Peek-a-boo is a suitable game for this age group as it helps develop visual tracking skills and the concept of object permanence. By covering and uncovering their face or a toy, the infant learns that things still exist even when they cannot be seen, promoting cognitive development and visual engagement.

5. A 3-year-old with a congenital heart defect has had a steady decrease in heart rate, now at 76 bpm from 110 bpm four hours ago. Which additional finding should be reported immediately to a healthcare provider?

• A. Oxygen saturation of 94%.
• B. Respiratory rate of 25 breaths/minute.
• C. Urine output of 20 mL/hr.
• D. Blood pressure of 70/40.

Correct answer: D

Rationale: A significant drop in heart rate and blood pressure should be reported immediately as it may indicate worsening of the congenital heart defect. The blood pressure of 70/40 is dangerously low and requires immediate attention to prevent further complications. Oxygen saturation of 94% is within an acceptable range and does not indicate immediate danger. A respiratory rate of 25 breaths/minute is slightly elevated but not a critical finding. Urine output of 20 mL/hr is low but may not be the most concerning finding in this scenario compared to the drop in blood pressure.

Similar Questions