Nursing Elites

1. Which observation of the exposed abdomen is most indicative of pyloric stenosis?

• A. abdominal rigidity
• B. substernal retraction
• C. palpable olive-like mass
• D. marked distention of the lower abdomen

Correct answer: C

Rationale: In pyloric stenosis, a palpable olive-like mass in the abdomen is a classic finding. This mass is due to the hypertrophied pyloric muscle. Abdominal rigidity (choice A) is associated with conditions like peritonitis, substernal retraction (choice B) is typically seen in respiratory distress, and marked distention of the lower abdomen (choice D) is more characteristic of conditions like intestinal obstruction rather than pyloric stenosis.

2. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?

• A. Deep-breathing exercises
• B. Upright positioning
• C. Coughing
• D. Chest percussion

Correct answer: B

Rationale: Upright positioning is the most appropriate intervention to promote maximum chest expansion in a child with Duchenne muscular dystrophy. By keeping the child in an upright position, lung expansion is maximized, which improves breathing efficiency. Deep-breathing exercises may help with overall lung function but do not directly promote chest expansion. Coughing and chest percussion are more related to airway clearance and do not specifically address maximizing chest expansion.

3. When assessing the perfusion status of a 2-year-old child with possible shock, which of the following parameters would be LEAST reliable?

• A. distal capillary refill
• B. systolic blood pressure
• C. skin color and temperature
• D. presence of peripheral pulses

Correct answer: B

Rationale: The correct answer is B: systolic blood pressure. In young children, systolic blood pressure is the least reliable parameter for assessing perfusion status. Factors such as anxiety, crying, and fear can significantly affect blood pressure measurements, leading to inaccuracies. Distal capillary refill, skin color and temperature, and presence of peripheral pulses are more reliable indicators of perfusion status in pediatric patients. Distal capillary refill assesses peripheral perfusion, skin color, and temperature reflect tissue perfusion, and the presence of peripheral pulses indicates blood flow to the extremities. Therefore, when evaluating a 2-year-old child with possible shock, focusing on parameters other than systolic blood pressure is crucial for an accurate assessment of perfusion status.

4. A child is admitted with extensive burns. The nurse notes burns on the child’s lips and singed nasal hairs. The nurse should suspect that the child has a(n)

• A. chemical burn
• B. inhalation injury
• C. electrical burn
• D. hot-water scald

Correct answer: B

Rationale: Burns on the lips and singed nasal hairs are indicative of an inhalation injury. This suggests that the child has likely inhaled hot gases or smoke, leading to damage in the respiratory tract. Choice A, chemical burn, is incorrect because the symptoms described are more aligned with inhalation rather than direct contact with chemicals. Choice C, electrical burn, is incorrect as there are no mentions of contact with an electrical source. Choice D, hot-water scald, is also incorrect as the presentation of burns on the lips and singed nasal hairs is not characteristic of scald injuries.

5. The school nurse is presenting a class to a group of students about common overuse disorders. Which disorder would the school nurse include?

• A. Dislocated radial head
• B. Transient synovitis of the hip
• C. Osgood-Schlatter disease
• D. Scoliosis

Correct answer: C

Rationale: The correct answer is C: Osgood-Schlatter disease. This condition is a common overuse injury that affects the knee. Osgood-Schlatter disease typically occurs in children and adolescents who are involved in activities that require frequent running, jumping, and kicking. It is characterized by pain, swelling, and tenderness at the tibial tuberosity, where the patellar tendon inserts into the tibia. Choice A, Dislocated radial head, is not an overuse disorder but rather a form of elbow injury where the head of the radius bone is displaced from its normal position. Choice B, Transient synovitis of the hip, is a self-limiting condition that causes hip pain and limping in children. It is not typically considered an overuse disorder. Choice D, Scoliosis, is a condition characterized by an abnormal lateral curvature of the spine. While it may be related to certain activities or postures, it is not primarily classified as an overuse disorder.

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