Nursing Elites

1. Which of the following is a common issue experienced by families of children with ASD?

• A. Financial limitations
• B. Social isolation
• C. Difficulty accessing needed services
• D. Difficulty obtaining early diagnosis

Correct answer: C

Rationale: Families of children with ASD commonly experience challenges in accessing needed services. This can include difficulties in obtaining appropriate therapies, educational support, and specialized interventions. While financial limitations and social isolation are also significant issues faced by these families, the primary concern often revolves around the challenges in accessing essential services for their children.

2. A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?

• A. Spinal cord injury
• B. Increased intracranial pressure
• C. Typical for sleep
• D. Improvement

Correct answer: B

Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.

3. When receiving change-of-shift report for children, which child should the nurse assess first?

• A. A toddler who has a concussion and an episode of forceful vomiting
• B. An adolescent with infective endocarditis who reports having a headache
• C. An adolescent who was placed into Halo traction 1 hour ago and rates his pain at a 6 on a 0-10 scale
• D. A school-age child with acute glomerulonephritis and brown-colored urine

Correct answer: A

Rationale: The nurse should assess the toddler with a concussion and an episode of forceful vomiting first when receiving change-of-shift report for children. Forceful vomiting in a toddler with a concussion indicates increased intracranial pressure, requiring immediate assessment and intervention to prevent further complications.

4. A school-age child has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?

• A. Palpate the dorsum of the child's feet
• B. Weigh the child daily using the same scale
• C. Assess the child's skin turgor
• D. Observe the child for periorbital swelling

Correct answer: A

Rationale: To confirm peripheral edema in a child, the nurse should palpate the dorsum of the child's feet by pressing a fingertip against a bony prominence for 5 seconds. This assessment helps detect the presence of pitting edema, which is characterized by an indentation that remains after the pressure is released.

5. A school nurse is assessing a school-age child�s blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?

• A. Clear the immediate area around the child of hazardous objects
• B. loosen the child�s restrictive clothing
• C. assist the child to a side-lying position on the floor
• D. apply an oxygen mask to the child

Correct answer: C

Rationale: The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling out of the chair. The nurse should ease the child down to the floor in a side-lying position immediately.

Similar Questions