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. 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 indicate inhalation injury, suggesting the child has inhaled hot gases or smoke. This presentation is common in cases where the respiratory tract is exposed to hot gases or smoke, leading to potential airway compromise. Choice A, chemical burn, is incorrect because there is no mention of exposure to chemicals, and the symptoms described are more indicative of inhalation injury. Choice C, electrical burn, is incorrect as there is no evidence of electrical involvement in the scenario provided. Choice D, hot-water scald, is incorrect because the presence of singed nasal hairs points more towards inhalation injury than a scald from hot water, emphasizing the need to prioritize airway management and respiratory support.

3. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?

• A. Quality of the cry
• B. Signs of dehydration
• C. Coughing up feedings
• D. Characteristics of the stool

Correct answer: B

Rationale: The correct answer is B: Signs of dehydration. Assessing for signs of dehydration is crucial in infants with hypertrophic pyloric stenosis (HPS) because they are at high risk due to frequent vomiting. Dehydration can lead to serious complications if not promptly addressed. Choices A, C, and D are not the priority assessments for HPS. While the quality of the cry can provide some information on the infant's distress level, dehydration assessment takes precedence. Coughing up feedings may not be specific to HPS, and characteristics of the stool, although important in general assessments, are not the priority in this situation.

4. A child is brought to the clinic after tripping over a rock. The child states, 'I twisted my ankle,' and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

• A. For the first 24 hours, apply ice for 20 minutes and remove for 60 minutes.
• B. Bed rest with the leg elevated for 36 hours.
• C. May take an NSAID for pain as prescribed.
• D. Use a compression dressing for 72 hours.

Correct answer: A

Rationale: The correct answer is A. Applying ice in intervals helps to reduce swelling and pain in the first 24 hours after a sprain. This intervention is crucial in the initial management of a sprain to decrease inflammation and provide pain relief. Bed rest with the leg elevated for 36 hours (Choice B) is not recommended as prolonged immobilization can lead to stiffness and decreased range of motion. Allowing the child to take an NSAID for pain as prescribed (Choice C) is a supportive measure but not as essential as ice application in the acute phase. Using a compression dressing for 72 hours (Choice D) may assist in reducing swelling, but it is not as critical as the immediate application of ice to manage pain and inflammation effectively.

5. Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly?

• A. Encourage them to express their concerns.
• B. Discourage them from talking about their baby.
• C. Assure them not to worry because the anomaly can be repaired.
• D. Show them postoperative photographs of infants who had a similar anomaly.

Correct answer: A

Rationale: Encouraging parents to express their concerns is the most supportive intervention as it allows them to process their emotions and provides an opportunity for the nurse to offer appropriate support and information. This choice focuses on validating the parents' feelings and creating an open communication channel. Choices B and C are incorrect as they can hinder the parents' emotional processing and may provide false reassurance. Choice D, showing postoperative photographs, may not be appropriate at this stage as it might not address the parents' current emotional needs and could induce anxiety or unrealistic expectations.

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