Nursing Elites

1. The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as the infant should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?

• A. Does the infant move a toy back and forth from one hand to the other?
• B. Is the infant able to drink from a cup by oneself?
• C. Is the infant able to hold a pencil and scribble on paper?
• D. Does the infant place toys into a box or container and take them out?

Correct answer: A

Rationale: The correct answer is A. By 8 months, an infant should be able to transfer objects between hands, which is an important motor skill milestone. This action shows coordination and developing fine motor skills. Choices B, C, and D involve more advanced motor skills that are typically not expected at 8 months of age. Drinking from a cup, holding a pencil to scribble, and engaging in purposeful play with toys are skills that develop later in infancy.

2. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

• A. Thirst
• B. Irritability
• C. Apprehension
• D. Confusion and somnolence

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

3. A school-age client is in the playroom when the respiratory therapist arrives to give a scheduled breathing treatment. What is the most appropriate nursing action?

• A. Escort the child to their room and ask the child-life specialist to bring toys to the bedside
• B. Reschedule the treatment for a later time
• C. Assist the child back to their room for the treatment but reassure them that they may return when the procedure is completed
• D. Show the respiratory therapist to the playroom

Correct answer: C

Rationale: The most appropriate action is to assist the child back to their room for the treatment but reassure them that they may return when the procedure is completed. This approach ensures that the child receives the necessary treatment while also acknowledging their desire to continue playing in the playroom. Choice A is incorrect because it suggests moving the child to the room and asking the child-life specialist to bring toys, which may not be necessary. Choice B is incorrect as rescheduling the treatment may not be in the best interest of the child's health. Choice D is incorrect as the nurse should guide the child back to their room for the treatment.

4. What is an important consideration in understanding the reactions of parents when their infant is born with physical defects?

• A. Grief lasts until the defects are repaired.
• B. Denial is a common adaptive reaction.
• C. The psychologic reaction is similar to that with the death of an infant.
• D. Reactions of health professionals to the birth of an infant can affect parents’ reactions.

Correct answer: C

Rationale: When a parent's infant is born with physical defects, understanding the psychological reactions is crucial. The reaction is often similar to the grief experienced when facing the death of a child. Parents need to grieve for the loss of the expected child and adapt to the needs of a child with physical defects. The grief process typically involves stages like shock, frustration, and anger, which can last for years. Denial during the shock phase is not maladaptive but can help parents cope initially. Additionally, parents are sensitive to the behavior of health professionals, whose interactions can significantly influence the parents' reactions to the infant. Therefore, recognizing the similarity of the psychological reaction to grief is an important consideration in understanding how parents cope with their infant's physical defects.

5. The nurse is preparing to admit a 6-year-old child with celiac disease. What clinical manifestations should the nurse expect to observe?

• A. Steatorrhea
• B. All are correct
• C. Malnutrition
• D. Foul-smelling stools

Correct answer: B

Rationale: Celiac disease often presents with steatorrhea, malnutrition, and foul-smelling stools due to the malabsorption of nutrients. Therefore, all the manifestations listed (steatorrhea, malnutrition, foul-smelling stools) are expected in a child with celiac disease. Polycythemia is not associated with celiac disease, making choice B the correct answer.

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