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. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?

• A. Quality of the cry
• B. Signs of dehydration
• C. Coughing up feedings
• D. Characteristics of the stool

Correct answer: B

Rationale: The correct answer is B: Signs of dehydration. Assessing for signs of dehydration is crucial in infants with hypertrophic pyloric stenosis (HPS) because they are at high risk due to frequent vomiting. Dehydration can lead to serious complications if not promptly addressed. Choices A, C, and D are not the priority assessments for HPS. While the quality of the cry can provide some information on the infant's distress level, dehydration assessment takes precedence. Coughing up feedings may not be specific to HPS, and characteristics of the stool, although important in general assessments, are not the priority in this situation.

3. A nurse is assessing a 2-year-old child with suspected Down syndrome. What characteristic physical feature is the nurse likely to observe?

• A. Epicanthal folds
• B. Webbed neck
• C. Enlarged head
• D. Polydactyly

Correct answer: A

Rationale: Epicanthal folds are a distinctive physical feature commonly observed in individuals with Down syndrome. These are horizontal skin folds that cover the inner corners of the eyes. Webbed neck (choice B) is not typically associated with Down syndrome but can be seen in conditions like Turner syndrome. Enlarged head (choice C) is not a characteristic feature of Down syndrome; however, individuals with hydrocephalus may present with this finding. Polydactyly (choice D) is the presence of extra fingers or toes, which is not a typical feature of Down syndrome.

4. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the healthcare provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL. This range is considered safe to prevent overdistension and potential harm to the child's rectum. Choices A, C, and D exceed the safe range for a 2-year-old child and can lead to complications such as bowel perforation or electrolyte imbalances.

5. A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?

• A. Monitoring fluid and electrolyte balance
• B. Encouraging regular exercise
• C. Administering antipyretics
• D. Administering antibiotics

Correct answer: A

Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract leading to diarrhea and vomiting, which can result in dehydration and electrolyte imbalances. Therefore, the priority nursing intervention is to monitor and maintain the child's fluid and electrolyte balance to prevent complications. Encouraging regular exercise (Choice B) may not be appropriate initially for a child with gastroenteritis who needs rest and fluid replacement. Administering antipyretics (Choice C) is not the priority unless the child has a fever. Administering antibiotics (Choice D) is not indicated for viral gastroenteritis, which is the most common cause of the condition.

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