Nursing Elites

1. What is the most appropriate action for a child with epistaxis?

• A. Have the child lie flat
• B. Pinch the nose and lean forward
• C. Apply a warm compress to the nose
• D. Encourage deep breathing

Correct answer: B

Rationale: The most appropriate action for a child with epistaxis is to pinch the nose and lean forward. This technique helps stop the bleeding and prevent aspiration of blood. By applying pressure to the bleeding vessels and allowing the blood to drain out of the nostrils instead of being swallowed, the risk of nausea and airway obstruction is reduced. Having the child lie flat (Choice A) may lead to blood flowing down the throat, causing potential choking. Applying a warm compress (Choice C) is not typically recommended for epistaxis as cold compresses are more effective. Encouraging deep breathing (Choice D) is not directly related to managing epistaxis.

2. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?

• A. Cyst
• B. Papule
• C. Pustule
• D. Vesicle

Correct answer: D

Rationale: A vesicle is an elevated, circumscribed lesion filled with serous fluid, typically less than 1 cm in diameter.

3. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?

• A. Keep baby powder out of reach.
• B. Inspect toys for removable parts.
• C. Allow the infant to take a bottle to bed.
• D. Teething biscuits can be used for teething discomfort.

Correct answer: A

Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.

4. A mother delivers an infant at 30 weeks gestation and asks if formula is better than breast milk since the baby is premature. What should the nurse respond?

• A. Human milk is preferred over other types of nutrition
• B. Human milk lacks essential nutrients for preterm infants
• C. Commercial infant formulas are preferred for preterm infants
• D. Commercial formulas have not been designed to meet preterm infants' needs

Correct answer: A

Rationale: Human milk is preferred, even for preterm infants, because it contains essential nutrients and antibodies that are particularly beneficial for their growth and development. Choice B is incorrect because human milk is rich in essential nutrients necessary for preterm infants. Choice C is incorrect as commercial infant formulas do not provide the same benefits as human milk. Choice D is incorrect as specialized formulas are available to meet the unique nutritional needs of preterm infants, but human milk remains the optimal choice.

5. The nurse is assessing a 3-year-old African American child whose height and weight are at the 20th percentile on the growth chart. What should the nurse recognize?

• A. The data suggest the child requires nutritional intervention
• B. The NCHS charts are accurate for U.S. African American children
• C. A correction factor is used for nonwhite ethnic groups
• D. No assessment can be made until several measurements are plotted over time

Correct answer: B

Rationale: The NCHS growth charts serve as reference guides for all racial or ethnic groups, including African American children. The 20th percentile for height and weight does not indicate nutritional failure but provides a reference point for ongoing assessment. Choice A is incorrect because being at the 20th percentile does not automatically imply the need for nutritional intervention. Choice C is incorrect as there is no correction factor specifically used for nonwhite ethnic groups in this context. Choice D is incorrect as a single measurement at the 20th percentile can provide valuable information for assessment.

Similar Questions