Nursing Elites

1. The parents of a newborn with phenylketonuria (PKU) need help and support in adhering to specific dietary restrictions. They ask the nurse, “How long will our child have to be on this diet?” How should the nurse respond?

• A. “We are still not sure; you should discuss this with your health care provider.”
• B. “If your baby does well, foods containing protein can gradually be introduced.”
• C. “Your child needs to be on this diet at least through adolescence and into adulthood.”
• D. “This is a lifelong problem, and it is recommended that dietary restrictions must be continued.”

Correct answer: D

Rationale: The correct answer is D: “This is a lifelong problem, and it is recommended that dietary restrictions must be continued.” Phenylketonuria (PKU) is a metabolic disorder where the body cannot process phenylalanine properly. The diet for PKU must be continued lifelong to prevent cognitive and developmental issues, as phenylalanine buildup can cause irreversible damage. Choice A is incorrect because the nurse should provide information about the lifelong nature of the dietary restrictions for PKU. Choice B is incorrect as it suggests reintroducing protein-containing foods, which is not recommended for individuals with PKU. Choice C is incorrect as it underestimates the duration of the necessary dietary restrictions for PKU.

2. Which of the following parameters would be LEAST reliable when assessing the perfusion status of a 2-year-old child with possible shock?

• A. distal capillary refill
• B. systolic blood pressure
• C. skin color and temperature
• D. presence of peripheral pulses

Correct answer: B

Rationale: Systolic blood pressure is the least reliable parameter when assessing the perfusion status of a 2-year-old child with possible shock. In pediatric patients, especially young children, blood pressure may not decrease until significant shock has already occurred, making it a late indicator of inadequate perfusion. Depending solely on systolic blood pressure to evaluate perfusion status in this age group can lead to a delay in appropriate interventions. Distal capillary refill time, skin color, and temperature changes, and the presence of peripheral pulses are more sensitive and early indicators of perfusion status in pediatric patients. Monitoring distal capillary refill provides information on peripheral perfusion, while changes in skin color and temperature can signal circulatory compromise. Evaluating the presence or absence of peripheral pulses offers insights into vascular perfusion. These parameters offer more reliable and prompt feedback on a child's perfusion status compared to systolic blood pressure.

3. The nurse is caring for a 1-month-old girl with low-set ears and severe hypotonia who was diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?

• A. Interrupted family process related to the child's diagnosis
• B. Deficient knowledge related to the genetic disorder
• C. Grieving related to the child's poor prognosis
• D. Ineffective coping related to stress from providing care

Correct answer: C

Rationale: The correct nursing diagnosis would be 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience feelings of grief and loss when dealing with such a diagnosis. The choice 'Interrupted family process' does not directly address the emotional response to the prognosis. 'Deficient knowledge' may be a concern but does not address the emotional aspect of dealing with a poor prognosis. 'Ineffective coping related to stress from providing care' focuses more on the caregiver's ability to cope rather than the family's response to the child's condition.

4. On the third day of hospitalization, the nurse observes that a 2-year-old toddler who had been screaming and crying inconsolably begins to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?

• A. Denial
• B. Despair
• C. Mistrust
• D. Rejection

Correct answer: B

Rationale: The correct answer is B: Despair. In separation anxiety, the stage of despair is characterized by regression and withdrawal after an initial period of protest. The child may become quiet and appear to accept the separation, but this is actually a sign of deeper distress. Choice A, Denial, is incorrect as it refers to refusing to believe or accept the reality of the separation. Choice C, Mistrust, is incorrect as it pertains to a lack of trust in others, not a stage of separation anxiety. Choice D, Rejection, is incorrect as it involves pushing others away and not related to the described behavior of the toddler in the scenario.

5. A parent tells the nurse, “My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises.” How should the nurse explain these changes in behavior?

• A. “I will check these responses before deciding how to proceed.”
• B. “Failure of these responses may be related to a developmental delay.”
• C. “Additional sensory stimulation is needed to aid in the return of these responses.”
• D. “These responses are replaced by voluntary activity at about five months of age.”

Correct answer: D

Rationale: The correct answer is D: “These responses are replaced by voluntary activity at about five months of age.” The grasp reflex and startle reflex (Moro reflex) are normal in newborns but typically disappear as the infant's nervous system matures and voluntary control develops. Choice A is incorrect because checking the responses before deciding a course of action does not address the developmental milestone related to the reflexes. Choice B is incorrect as it jumps to a conclusion of developmental delay without considering the normal developmental process. Choice C is incorrect as additional sensory stimulation is not necessary for the return of these reflexes, as they are expected to naturally diminish as part of normal development.

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