Nursing Elites

1. When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?

• A. Skeletal traction
• B. Physical therapy
• C. Orthotics
• D. Occupational therapy

Correct answer: A

Rationale: In caring for a child with cerebral palsy, skeletal traction is least likely to be a part of the treatment plan. Cerebral palsy is a neurological disorder affecting movement and muscle coordination, and skeletal traction, which involves applying a pulling force on a bone to correct alignment, is not a common intervention for this condition. Physical therapy, orthotics, and occupational therapy are more commonly used in the management of cerebral palsy. Physical therapy helps improve mobility and strength, orthotics assist in supporting and aligning the body, and occupational therapy focuses on enhancing daily living skills and independence. Therefore, skeletal traction is the least likely treatment option among the choices provided.

2. What should be included in the nursing plan of care for a 6-month-old infant admitted to the pediatric unit with a diagnosis of respiratory syncytial virus (RSV)?

• A. Place the infant in a warm, dry environment.
• B. Allow parents and siblings to visit.
• C. Maintain standard and contact precautions.
• D. Administer prescribed antibiotics immediately.

Correct answer: C

Rationale: The correct answer is C: Maintain standard and contact precautions. RSV is highly contagious, primarily spread through respiratory secretions. Therefore, it is crucial to implement infection control measures such as standard and contact precautions to prevent the spread of the virus to other patients, staff, and visitors. Choice A is incorrect because warmth and dryness are not specific interventions for RSV; the focus should be on infection control. Choice B may increase the risk of exposing others to RSV, so limiting visitors is recommended. Choice D is unnecessary because RSV is a viral infection, and antibiotics are not effective against viruses.

3. A child who had surgery for a congenital heart defect is being discharged. What is an important aspect of the discharge teaching?

• A. Teaching the parents about signs of infection
• B. Providing instructions on wound care
• C. Scheduling follow-up appointments
• D. Explaining the use of prescribed medications

Correct answer: D

Rationale: Explaining the use of prescribed medications is crucial as it helps ensure the proper management of the child's condition post-discharge. Understanding how and when to administer medications is essential for the child's recovery. While teaching the parents about signs of infection, providing wound care instructions, and scheduling follow-up appointments are also important aspects of care, ensuring the correct use of prescribed medications takes precedence to prevent complications and promote the child's well-being.

4. During the second week of hospitalization for intravenous antibiotic therapy, a 2-year-old toddler whose family is unable to visit often smiles easily, goes to all the nurses happily, and does not express interest in the parent when the parent does visit. The parent tells the nurse, 'I am pleased about the adjustment but somewhat concerned about my child’s reaction to me.' How should the nurse respond?

• A. The child is repressing feelings for the parent.
• B. Routines have been established, and the child feels safe.
• C. The child has given up fighting and accepts the separation.
• D. Behavior has improved because the child feels better physically.

Correct answer: C

Rationale: The correct answer is C: 'The child has given up fighting and accepts the separation.' This response indicates that the child is emotionally withdrawing due to the separation from the parent during hospitalization. Choice A is incorrect because the child's behavior does not necessarily suggest repressed feelings for the parent. Choice B is incorrect as feeling safe due to established routines does not fully explain the child's behavior. Choice D is incorrect because while feeling better physically may contribute to improved behavior, it does not address the emotional aspect of the child's reaction to the parent.

5. A health care provider orders a tap water enema for a 6-month-old infant with suspected Hirschsprung disease. What rationale causes the nurse to question the order?

• A. The result could lead to loss of necessary nutrients.
• B. It could cause a fluid and electrolyte imbalance.
• C. It could increase the fear of intrusive procedures.
• D. The result could cause shock from a sudden drop in temperature.

Correct answer: B

Rationale: The correct answer is B. Tap water enemas can cause significant fluid and electrolyte imbalances, particularly in infants, making them unsafe for this age group. Choice A is incorrect because tap water enemas do not directly lead to loss of necessary nutrients. Choice C is incorrect as it focuses on emotional impact rather than physiological risks. Choice D is incorrect as shock from a sudden drop in temperature is not a common consequence of a tap water enema in this scenario.

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