Nursing Elites

1. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

• A. Oliguria
• B. Weight loss
• C. Irritability and seizures
• D. Muscle weakness and cardiac dysrhythmias

Correct answer: C

Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.

2. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

• A. It is best to wait until the child asks about it.
• B. The best time to tell the child is between the ages of 7 and 10 years.
• C. It is not necessary to tell a child who was adopted so young.
• D. Telling the child is an important aspect of their parental responsibilities.

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

3. Parents would suspect hearing loss if their child did not:

• A. Turn away from a sound
• B. Startle with sudden loud noises immediately after birth
• C. Talk at 4 months
• D. Babble at 2 months

Correct answer: D

Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.

4. What is a common cause of acquired aplastic anemia in children?

• A. Deficient diet
• B. Ingestion of drugs such as chloramphenicol or antiepileptics
• C. Congenital defects
• D. Injury

Correct answer: B

Rationale: The correct answer is B. Acquired aplastic anemia in children is often caused by exposure to certain drugs, such as chloramphenicol or antiepileptics, which can lead to bone marrow failure and a decrease in all types of blood cells. Choices A, C, and D are incorrect because aplastic anemia is not commonly caused by deficient diet, congenital defects, or injury in children.

5. The child is admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation?

• A. Place the child in the Trendelenburg position.
• B. Apply moist heat to the abdomen.
• C. Allow the child to assume a position of comfort.
• D. Administer a saline enema to cleanse the bowel.

Correct answer: C

Rationale: Allowing the child to assume a position of comfort is appropriate as it helps alleviate discomfort without the risk of complications. Placing the child in the Trendelenburg position could increase intra-abdominal pressure and worsen the condition. Applying moist heat may lead to vasodilation and potential perforation in case of appendicitis. Administering a saline enema can be harmful if the appendix is inflamed or perforated.

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