Nursing Elites

1. What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?

• A. Measuring the abdomen after feedings
• B. Marking the point of measurement with a pen
• C. Measuring the circumference at the symphysis pubis
• D. Using a new tape measure with each assessment to ensure accuracy

Correct answer: B

Rationale: Marking the point of measurement ensures consistent and accurate assessments of abdominal circumference, especially important in conditions like bowel obstruction where changes need to be monitored closely.

2. The nurse is testing an infant's visual acuity. By which age should the infant be able to fix on and follow a target?

• A. 1 month
• B. 1 to 2 months
• C. 3 to 4 months
• D. 6 months

Correct answer: C

Rationale: By 3 to 4 months of age, an infant should be able to fix on and follow a target, indicating proper visual development.

3. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?

• A. Not useful as the only indicator for pain
• B. Best indicator of pain in children of all ages
• C. Most valuable when children also report having pain
• D. Essential to determine whether a child is telling the truth about pain

Correct answer: A

Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.

4. What term describes the invagination of one segment of bowel within another?

• A. Atresia
• B. Stenosis
• C. Herniation
• D. Intussusception

Correct answer: D

Rationale: Intussusception is the correct answer. It refers to the condition where one segment of the bowel folds into another, leading to an obstruction. Atresia (Choice A) is the absence or abnormal closure of a normal opening or tubular structure. Stenosis (Choice B) is the narrowing of a passage in the body. Herniation (Choice C) is the abnormal protrusion of an organ or tissue through a defect in its surrounding walls. Intussusception is a medical emergency commonly observed in infants and young children and necessitates prompt intervention to prevent severe complications.

5. An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what?

• A. Cystic fibrosis
• B. Hyperthyroidism
• C. Congenital infection
• D. Breastfeeding problems

Correct answer: C

Rationale: FTT classified as defective utilization is often related to conditions like congenital infections, which interfere with the body's ability to effectively use nutrients. Conditions like cystic fibrosis and hyperthyroidism can also contribute to FTT but are categorized differently

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