Nursing Elites

1. When assessing a child with suspected meningitis, which finding is a characteristic sign of meningitis?

• A. High-pitched cry
• B. Tachycardia
• C. Photophobia
• D. Hypotension

Correct answer: C

Rationale: Photophobia, which is sensitivity to light, is a characteristic sign of meningitis in children. It commonly presents along with symptoms such as headache and neck stiffness. This symptom is important to recognize early for prompt diagnosis and treatment of meningitis.

2. When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?

• A. Determine what activities, foods, and toys the child enjoys
• B. Evaluate the child’s previous reactions to punishment
• C. Provide the child with positive feedback
• D. Encourage other children on the unit to describe the token system

Correct answer: A

Rationale: The first step in developing a behavior modification program for an aggressive child is to determine what activities, foods, and toys the child enjoys. Understanding the child's preferences allows the nurse to personalize the program, making it more engaging and effective. This approach increases the chances of success in modifying the aggressive behavior. Evaluating previous reactions to punishment (Choice B) may be important but comes later in the process. Providing positive feedback (Choice C) is beneficial but should come after tailoring the program. Encouraging other children to describe the token system (Choice D) is not the initial step; the focus should be on individualizing the program for the specific child first.

3. The parents of a 10-year-old child with newly diagnosed type 1 diabetes are being taught by the nurse about managing their child’s condition. Which statement by the parents indicates they need further teaching?

• A. We should rotate injection sites to prevent tissue damage
• B. Our child should avoid all sugary foods and drinks
• C. We will monitor blood glucose levels regularly
• D. Our child needs to wear a medical alert bracelet

Correct answer: B

Rationale: It is important for individuals with diabetes to manage their carbohydrate intake, including sugary foods and drinks, rather than completely avoiding them. Sugary foods should be consumed in moderation as part of a balanced diet to help maintain stable blood glucose levels.

4. The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the procedure. What intervention should the nurse implement?

• A. Instruct the parents that the infant needs to be NPO.
• B. Notify the healthcare provider of the passage of brown stool.
• C. Obtain a stool specimen for laboratory analysis.
• D. Ask the parents about recent changes in the infant's diet.

Correct answer: B

Rationale: Notifying the healthcare provider is crucial when an infant scheduled for intussusception reduction passes a soft-formed brown stool as it may indicate spontaneous reduction of the intussusception. The healthcare provider needs to be informed to assess if the procedure is still necessary or if further evaluation is required. Instructing the parents that the infant needs to be NPO (nothing by mouth) is not the immediate action required in this situation. Obtaining a stool specimen for laboratory analysis is not necessary as the soft-formed brown stool is likely a result of the intussusception spontaneously reducing. Asking about recent changes in the infant's diet is not the most appropriate action when brown stool is passed before the procedure for intussusception reduction.

5. A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant’s vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?

• A. Irregular palpable pulse
• B. Hyperactive bowel sounds
• C. Underweight for age
• D. Crying without tears

Correct answer: D

Rationale: In this scenario, the infant presenting with vomiting, lethargy, and projectile vomiting indicates a potential serious condition. Crying without tears is a sign of dehydration, a critical condition that can lead to life-threatening complications in infants. Dehydration can rapidly worsen an infant's condition, making prompt intervention crucial to prevent further complications. Irregular palpable pulse (Choice A) could indicate a cardiovascular issue but is less immediately life-threatening in this context. Hyperactive bowel sounds (Choice B) are more indicative of gastrointestinal issues rather than a life-threatening complication. Underweight for age (Choice C) may be concerning for growth-related issues but does not directly indicate a life-threatening complication like dehydration does.

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