Nursing Elites

1. Which explains the importance of detecting strabismus in young children?

• A. Color vision deficit may result.
• B. Amblyopia, a type of blindness, may result.
• C. Epicanthal folds may develop in the affected eye
• D. Corneal light reflexes may fall symmetrically within each pupil

Correct answer: B

Rationale: Undetected strabismus can lead to amblyopia, where the brain favors one eye over the other, potentially resulting in permanent vision loss in the affected eye.

2. The child is admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation?

• A. Place the child in the Trendelenburg position.
• B. Apply moist heat to the abdomen.
• C. Allow the child to assume a position of comfort.
• D. Administer a saline enema to cleanse the bowel.

Correct answer: C

Rationale: Allowing the child to assume a position of comfort is appropriate as it helps alleviate discomfort without the risk of complications. Placing the child in the Trendelenburg position could increase intra-abdominal pressure and worsen the condition. Applying moist heat may lead to vasodilation and potential perforation in case of appendicitis. Administering a saline enema can be harmful if the appendix is inflamed or perforated.

3. The parent of a 1-month-old infant voices concern about the infant’s respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?

• A. The normal respiratory rate for an infant at this age is between 20 and 30 breaths per minute.
• B. The respirations of a 1-month-old infant are normally irregular and periodically pause.
• C. An infant at this age should have regular respirations.
• D. The irregularity of the infant's respirations is concerning; I will notify the health care provider.

Correct answer: B

Rationale: The correct answer is B. Irregular respirations with periodic pauses are normal in a 1-month-old infant. Choice A is incorrect because the normal respiratory rate for an infant at this age is higher than the range provided. Choice C is incorrect as irregular respirations are expected in infants. Choice D is not appropriate as irregular respirations with periodic pauses are a normal finding in young infants and do not necessarily indicate a concern that requires immediate notification of the healthcare provider.

4. The school nurse is assessing children for risk factors related to childhood injuries. Which child has the most risk factors related to childhood injury?

• A. Female, multiple siblings, stable home life
• B. Male, high activity level, stressful home life
• C. Male, even-tempered, history of previous injuries
• D. Female, reacts negatively to new situations, no serious previous injuries

Correct answer: B

Rationale: A male child with a high activity level and a stressful home life has multiple risk factors for childhood injuries, requiring closer supervision and preventive measures.

5. An eleven-year-old boy is admitted with a history of type 1 diabetes. What information about school age should the nurse use to formulate the teaching plan for daily injections?

• A. The parents do not need to learn the procedure.
• B. The child is old enough to give most of his injections.
• C. Self-injections will be possible when he is closer to adolescence.
• D. The child can learn about self-injections when he is able to reach all injection sites.

Correct answer: B

Rationale: By the age of eleven, many children are capable of administering their own insulin injections with supervision, fostering independence and better management of their diabetes. This age is appropriate for the child to take on more responsibility for their care. While parental involvement is still crucial for supervision and guidance, the child can start to learn and perform the injections themselves. Choice A is incorrect because parental involvement is important for safety and proper technique. Choice C is incorrect as waiting until closer to adolescence may delay the child's ability to manage their diabetes effectively. Choice D is incorrect as reaching injection sites is not the sole criteria; proper technique and supervision are essential.

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