Nursing Elites

1. 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.

2. The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?

• A. One portion of the intestines invaginates or telescopes into another
• B. Hypertrophy of the circular pylorus muscle
• C. Relaxed cardiac sphincter
• D. Absent ganglion cells in the colon

Correct answer: B

Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.

3. The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.)

• A. Hyponatremia
• B. Hyperkalemia
• C. All are applicable
• D. Elevated blood urea nitrogen level

Correct answer: C

Rationale: In acute renal failure, laboratory findings typically include hyperkalemia, hyponatremia, and elevated blood urea nitrogen (BUN) levels due to the kidneys' inability to excrete waste and balance electrolytes. Metabolic alkalosis is less common, with metabolic acidosis being more typical.

4. Which best describes signs and symptoms as part of a nursing diagnosis?

• A. Description of potential risk factors
• B. Identification of actual health problems
• C. Human response to state of illness or health
• D. Cues and clusters derived from patient assessment

Correct answer: D

Rationale: Signs and symptoms are cues and clusters derived from patient assessments that are used to form a nursing diagnosis, guiding the development of a care plan.

5. The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?

• A. History
• B. Present illness
• C. Chief complaint
• D. Review of systems

Correct answer: A

Rationale: The history section of the health record includes details about pregnancy, labor, and delivery, as these factors can have significant implications for the child's health.

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