Nursing Elites

1. When assessing the breath sounds of an 18-month-old child who is crying, what action should the healthcare professional take?

• A. Document that the assessment is not available because the child is crying.
• B. Ask the caregiver to quiet the child so breath sounds can be auscultated.
• C. Allow the child to play with a stethoscope to distract them during auscultation.
• D. Auscultate and document breath sounds, noting that the child was crying at the time.

Correct answer: C

Rationale: Allowing the child to play with a stethoscope can help distract them, making it easier to auscultate breath sounds. This approach can create a more cooperative and engaging environment for the child, facilitating a more accurate assessment of their breath sounds. Choice A is incorrect because it does not address the need for an assessment. Choice B is not ideal as it puts pressure on the caregiver and may not be effective in calming the child. Choice D is not the best option as it does not actively involve the child in the assessment process and may not provide an accurate representation of their breath sounds.

2. The nurse is caring for a 4-year-old child who is hospitalized with pneumonia. The child is receiving IV antibiotics and oxygen therapy. The nurse notes that the child’s respiratory rate is 40 breaths per minute, and the oxygen saturation is 92%. What is the nurse’s priority action?

• A. Increase the child’s oxygen flow rate
• B. Notify the healthcare provider
• C. Encourage the child to take deep breaths
• D. Auscultate the child’s lung sounds

Correct answer: D

Rationale: In this scenario, the child is hospitalized with pneumonia, receiving IV antibiotics and oxygen therapy. With a high respiratory rate and decreased oxygen saturation, auscultating the child’s lung sounds is the priority action. This assessment can provide crucial information about the child’s respiratory status, such as the presence of adventitious sounds or decreased air entry, which can guide further interventions and help in evaluating the effectiveness of the current treatments. Increasing the oxygen flow rate may not address the underlying issue causing the decreased oxygen saturation. Notifying the healthcare provider can be necessary but auscultating lung sounds should be done first to gather more information. Encouraging the child to take deep breaths is important for respiratory function but should not be the immediate priority in this situation.

3. The healthcare provider is assessing a child for neurological soft signs. Which finding is most likely demonstrated in the child's behavior?

• A. Inability to move the tongue in a specific direction.
• B. Presence of vertigo.
• C. Poor coordination and sense of position.
• D. Loss of visual acuity.

Correct answer: C

Rationale: Neurological soft signs in children often manifest as poor coordination and a sense of position. These signs can indicate underlying neurological issues and are important to assess in pediatric patients. Choices A, B, and D are less likely to be associated with neurological soft signs in children. Inability to move the tongue in a specific direction may suggest a cranial nerve dysfunction rather than general neurological soft signs. Presence of vertigo is more related to inner ear disturbances or vestibular issues. Loss of visual acuity may indicate problems with the eyes rather than general neurological soft signs.

4. A child with Graves' disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response?

• A. Increased weight gain
• B. Decreased heart rate
• C. Reduced headaches
• D. Diminished fatigue

Correct answer: B

Rationale: When a child with Graves' disease is prescribed propranolol (Inderal), the nurse should monitor for a decreased heart rate as a therapeutic response. Propranolol is a beta-blocker that acts to slow down the heart rate, which is beneficial in managing the symptoms of Graves' disease, such as tachycardia and other cardiovascular manifestations. Choices A, C, and D are incorrect because propranolol is not typically associated with increased weight gain, reduced headaches, or diminished fatigue as its primary therapeutic effect in this context.

5. A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse’s priority intervention?

• A. Establish a therapeutic relationship with the client
• B. Monitor the client’s vital signs frequently
• C. Initiate a structured eating plan
• D. Provide education about healthy eating habits

Correct answer: C

Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.

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