Nursing Elites

1. What self-report pain rating scales can be used in children as young as 3 years of age?

• A. Poker Chip Tool
• B. Visual Analog Scale
• C. FACES Pain Rating Scale
• D. Word-Graphic Rating Scale

Correct answer: C

Rationale: The FACES Pain Rating Scale is suitable for children as young as 3 years of age. It uses facial expressions to depict different levels of pain, making it easy for young children to understand and use. The Poker Chip Tool is validated for children aged 4 and older who have a certain level of cognitive ability. The Visual Analog Scale is more appropriate for children aged 7 and above. The Word-Graphic Rating Scale, which uses descriptive words, is recommended for children in the age range of 4 to 17 years.

2. A four-year-old child has a history of repeated otitis media despite antibiotic treatment. Which treatment measure should the nurse discuss with the parents?

• A. Antibiotic treatment
• B. Adenoidectomy
• C. The insertion of tympanostomy (pressure equalizing) tubes
• D. Tonsillectomy

Correct answer: C

Rationale: The correct answer is C: The insertion of tympanostomy (pressure equalizing) tubes. This treatment measure is appropriate for a child with recurrent otitis media as it helps drain fluid from the middle ear and prevent further infections. Adenoidectomy (choice B) involves the removal of the adenoids, which may not directly address the ear infections. Antibiotic treatment (choice A) has already been ineffective in this case, so alternative measures are necessary. Tonsillectomy (choice D) is not typically indicated for otitis media unless there are specific reasons such as enlarged tonsils contributing to the condition.

3. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?

• A. Water excess
• B. Sodium excess
• C. Water depletion
• D. Potassium excess

Correct answer: C

Rationale: These symptoms are indicative of dehydration or water depletion, which is common in infants and can rapidly lead to severe consequences if not addressed promptly.

4. Parents of a newborn with ambiguous genitalia want to know how long they will have to wait to know whether they have a boy or a girl. The nurse answers the parents based on what knowledge?

• A. Chromosome analysis will be complete in 7 days.
• B. A physical examination will be able to provide a definitive answer.
• C. Additional laboratory testing is necessary to assign the correct gender.
• D. Gender assignment involves collaboration between the parents and a multidisciplinary team.

Correct answer: D

Rationale: Gender assignment in cases of ambiguous genitalia is a complex process that requires a multidisciplinary approach, including genetic, endocrinological, and psychological evaluations. The decision should be made collaboratively with the parents.

5. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?

• A. Recommend supplemental feedings of formula.
• B. Explain that this weight loss is within normal limits.
• C. Assess the child further to determine the cause of excessive weight loss.
• D. Encourage the mother to express breast milk for bottle-feeding the infant.

Correct answer: B

Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.

Similar Questions