Nursing Elites

1. What is the most appropriate nursing action when intermittently gavage feeding a preterm infant?

• A. Allow formula to flow by gravity
• B. Avoid allowing the infant to suck on the tube
• C. Insert the tube through the nares instead of the mouth
• D. Apply gentle pressure to the syringe to deliver the formula

Correct answer: A

Rationale: The correct action when intermittently gavage feeding a preterm infant is to allow the formula to flow by gravity. This method helps prevent overfeeding and aspiration, which can occur if the formula is delivered too quickly under pressure. Choice B is incorrect as sucking on the tube can cause complications. Choice C is incorrect as the tube is typically inserted through the mouth. Choice D is incorrect as steady pressure can lead to rapid delivery of the formula, increasing the risk of complications.

2. When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?

• A. Petechiae, fever, fatigue
• B. Headache, papilledema, irritability
• C. Muscle wasting, weight loss, fatigue
• D. Decreased intracranial pressure, psychosis, confusion

Correct answer: A

Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.

3. The nurse is caring for an adolescent who is overweight. Which of the following psychological effects of being overweight during adolescence will the nurse consider when planning care for the adolescent?

• A. Poor body image
• B. Sexual promiscuity
• C. Feelings of contempt for thin peers
• D. Lack of independence

Correct answer: A

Rationale: Adolescents who are overweight often struggle with poor body image, which can lead to low self-esteem and mental health issues. Addressing body image concerns and promoting healthy lifestyle changes are important aspects of care. Choices B, C, and D are incorrect. Sexual promiscuity is not a direct psychological effect of being overweight; feelings of contempt for thin peers are not a common or recommended psychological response; lack of independence is a broad term that does not specifically relate to the psychological effects of being overweight.

4. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?

• A. Place a warm moist pack on the scrotal area.
• B. Instruct the adolescent to lie down and elevate the legs.
• C. Refer the adolescent for immediate medical evaluation.
• D. Suggest that the adolescent wear a scrotum-protecting guard.

Correct answer: C

Rationale: Testicular torsion is a surgical emergency requiring immediate medical evaluation. Applying heat or elevating the legs will not alleviate the torsion, and delaying care can lead to testicular necrosis.

5. The nurse understands that blocks to therapeutic communication include what? (Select all that apply.)

• A. Socializing
• B. All are applicable
• C. Using clichés
• D. Defending a situation

Correct answer: B

Rationale: Socializing, using clichés, and defending a situation are all barriers to effective therapeutic communication. Silence is a useful tool in therapeutic communication.

Similar Questions