Nursing Elites

1. When screening a 5-year-old for strabismus, what action should the nurse take?

• A. Have the child identify colored patterns on polychromatic cards.
• B. Direct the child through the six cardinal positions of gaze.
• C. Inspect the child for the setting sun sign.
• D. Observe the child for blank, sunken eyes.

Correct answer: B

Rationale: When screening a 5-year-old for strabismus, directing the child through the six cardinal positions of gaze is the most appropriate action. This method helps the nurse to assess eye alignment, which is crucial in identifying any misalignment that may indicate strabismus. Choices A, C, and D are incorrect. Having the child identify colored patterns on polychromatic cards is more related to visual acuity testing rather than strabismus screening. Inspecting the child for the setting sun sign is not a standard method for strabismus screening. Observing the child for blank, sunken eyes is not specific to strabismus assessment.

2. A middle school student was recently diagnosed with attention-deficit hyperactivity disorder (ADHD) and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues to have learning problems. Which action should the school nurse take?

• A. Ask the parents to have the child seen by a clinical psychologist
• B. Ask the parents to become involved in helping the child with his homework
• C. Refer the child to the school counselor for educational testing
• D. Seek the advice of the school principal regarding the child's learning needs

Correct answer: C

Rationale: Referring the child to the school counselor for educational testing is the most appropriate action in this scenario. This step can help identify the specific learning needs of the student and determine the appropriate interventions required to support his academic success. Option A is not the immediate action needed but may be considered in the future. Option B focuses on homework assistance, which may not address the underlying learning problems. Option D involves consulting the school principal, which is not the primary role in addressing the student's learning needs.

3. When planning care for a child diagnosed with rheumatic fever, what is the primary goal of nursing care?

• A. Reduce fever.
• B. Maintain fluid and electrolyte balance.
• C. Prevent cardiac damage.
• D. Maintain joint mobility and function.

Correct answer: C

Rationale: The primary goal of nursing care for a child diagnosed with rheumatic fever is to prevent cardiac damage. Rheumatic fever can lead to complications affecting the heart, making it crucial to monitor and prevent cardiac involvement to avoid long-term consequences. While addressing fever and joint pain are important aspects of care, preventing cardiac damage takes precedence in managing rheumatic fever. Therefore, choices A, B, and D are not the primary goals of nursing care in this case.

4. What should the nurse do first for a 6-year-old with asthma showing a prolonged expiratory phase, wheezing, and 35% of personal best peak expiratory flow rate (PEFR)?

• A. Administer a prescribed bronchodilator.
• B. Encourage the child to cough and take deep breaths.
• C. Report the findings to the healthcare provider.
• D. Identify the triggers that precipitated this attack.

Correct answer: A

Rationale: Administering a bronchodilator is the priority action in managing an acute asthma exacerbation in a child. Bronchodilators help to relax the muscles around the airways, opening them up and improving breathing. This intervention aims to address the immediate breathing difficulty and should be done promptly to provide relief for the child. Encouraging coughing and deep breaths (choice B) may worsen the child's condition by further constricting the airways. Reporting findings to the healthcare provider (choice C) is important but not the immediate priority in this acute situation. Identifying triggers (choice D) is crucial for long-term asthma management but is not the first step when managing an acute exacerbation.

5. When should a mother introduce solid foods to her 4-month-old infant? The mother states that her mother suggests putting rice cereal in the baby's bottle. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

• A. Stops rooting when hungry
• B. Opens mouth when food is offered
• C. Awakens once for nighttime feedings
• D. Gives up a bottle for a cup

Correct answer: B

Rationale: Introducing solid foods when the child opens their mouth for food is important to ensure readiness for solids. This behavior indicates the infant's interest and readiness for new textures and flavors, promoting safe and successful introduction to solid foods. The other choices are not indicative of the infant's readiness for solid foods: A - stopping rooting is a reflex action, C - awakening for nighttime feedings is a normal behavior, and D - transitioning from a bottle to a cup is a developmental milestone unrelated to solid food introduction.

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