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. A child has been diagnosed with nephrotic syndrome, and a nurse is providing care. What is the priority nursing intervention?

• A. Administering diuretics
• B. Monitoring urine output
• C. Administering corticosteroids
• D. Restricting fluid intake

Correct answer: B

Rationale: The priority nursing intervention when caring for a child with nephrotic syndrome is monitoring urine output. This is essential for assessing kidney function and managing the condition effectively. Administering diuretics (Choice A) may be a part of the treatment plan but should not be the priority over monitoring urine output. Administering corticosteroids (Choice C) may also be a treatment for nephrotic syndrome, but monitoring urine output takes precedence. Restricting fluid intake (Choice D) may be necessary in some cases, but it is not the priority intervention compared to monitoring urine output for early detection of changes in kidney function.

3. Why might a healthcare provider question a health care provider's order for a tap water enema for a 6-month-old infant with suspected Hirschsprung disease?

• 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 are unlikely to lead to loss of necessary nutrients. Choice C is incorrect as it does not directly relate to the physiological risk of tap water enemas. Choice D is incorrect as shock from a sudden drop in temperature is not a common concern with tap water enemas.

4. During an assessment, a nurse is examining the skin of a child with cellulitis. What would the nurse expect to find?

• A. Red, raised hair follicles
• B. Warmth at skin disruption site
• C. Papules progressing to vesicles
• D. Honey-colored exudate

Correct answer: B

Rationale: The correct answer is B: 'Warmth at skin disruption site.' Cellulitis is characterized by localized warmth at the site of skin disruption, which indicates an infection. Choice A, 'Red, raised hair follicles,' is more typical of folliculitis. Choice C, 'Papules progressing to vesicles,' is suggestive of conditions like herpes simplex virus infections. Choice D, 'Honey-colored exudate,' is associated with impetigo, not cellulitis. When assessing cellulitis, nurses should primarily look for warmth, erythema, edema, and tenderness at the affected site.

5. A major developmental milestone of a toddler is the achievement of autonomy. What should the caregiver instruct the parents to do to enhance their toddler’s need for autonomy?

• A. Teach the child to share with others.
• B. Help the child learn society’s roles.
• C. Teach the child to accept external limits.
• D. Help the child develop internal controls.

Correct answer: D

Rationale: Toddlers are striving for autonomy during this developmental stage. Helping the child to develop internal controls, such as self-regulation and decision-making skills, enhances their sense of autonomy. Choice A, teaching the child to share, focuses more on social skills rather than autonomy. Choice B, helping the child learn society's roles, pertains to socialization rather than autonomy. Choice C, teaching the child to accept external limits, is about compliance with rules rather than fostering autonomy. Therefore, the most appropriate action to enhance a toddler's need for autonomy is to help them develop internal controls.

Similar Questions