Nursing Elites

1. Which of the following is a more reliable indicator of perfusion in children than in adults?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Capillary refill

Correct answer: D

Rationale: Capillary refill is a more reliable indicator of perfusion in children than in adults. This is because children have more compliant vessels, making capillary refill a more sensitive indicator of perfusion status in this population. In contrast, while blood pressure, heart rate, and respiratory rate are important indicators, they may not be as reliable in children as capillary refill. Blood pressure can be affected by various factors such as anxiety or pain, heart rate can be influenced by emotions or temperature, and respiratory rate may vary with activity levels. Therefore, capillary refill is preferred in children for a more accurate assessment of perfusion.

2. A 3-month-old is hospitalized with a fractured femur. The pain assessment tool most appropriate for this child is the:

• A. FLACC scale.
• B. Poker chip tool.
• C. Number scale.
• D. Visual analog scale.

Correct answer: A

Rationale: The FLACC scale is a validated pain assessment tool suitable for infants and young children, including 3-month-olds. It assesses pain based on five categories: Face, Legs, Activity, Cry, and Consolability. Since infants cannot communicate their pain verbally, the FLACC scale is effective in evaluating pain by observing these behavioral indicators. The other options, such as the Poker chip tool, Number scale, and Visual analog scale, are not specifically designed for infants and may not provide accurate pain assessment in this age group.

3. Which of the following statements regarding the length-based resuscitation tape measure is correct?

• A. The resuscitation tape estimates a child's weight based on his or her height.
• B. It is a reliable tool in children who are less than 5 years of age.
• C. The red end of the tape measure is placed at the top of the child's head.
• D. The tape measure can be used in children who weigh up to 75 pounds.

Correct answer: D

Rationale: The length-based resuscitation tape measure is designed to estimate a child's weight based on their length and can be used for children weighing up to 75 pounds. It is a reliable tool for pediatric weight estimation in emergency situations.

4. A 30-year-old woman is 22 weeks pregnant with her first child. She tells you that her rings are not fitting as loosely as they usually do and that her ankles are swollen. Her blood pressure is 150/86 mm Hg. She is MOST likely experiencing:

• A. a condition unrelated to pregnancy.
• B. gestational diabetes.
• C. a hypertensive emergency.
• D. preeclampsia.

Correct answer: D

Rationale: The symptoms of swollen ankles, tight rings, and elevated blood pressure in a pregnant woman at 22 weeks gestation are concerning for preeclampsia. Preeclampsia is characterized by high blood pressure and signs of organ damage, commonly seen with symptoms such as swelling (edema) and protein in the urine. It is crucial to monitor and manage preeclampsia promptly as it can lead to severe complications for both the mother and the baby.

5. Mrs. Byers tells the nurse that she is very worried because her 2-year-old child does not finish his meals. What should the nurse advise the mother?

• A. Make the child seat with the family in the dining room until he finishes his meal
• B. Provide quiet environment for the child before meals
• C. Do not give snacks to the child before meals
• D. Put the child on a chair and feed him

Correct answer: C

Rationale: Providing a quiet environment can help the child focus on eating.

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