Nursing Elites

1. Which of the following parameters would be LEAST reliable when assessing the perfusion status of a 2-year-old child with possible shock?

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

Correct answer: B

Rationale: Systolic blood pressure is the least reliable parameter when assessing the perfusion status of a 2-year-old child with possible shock. In pediatric patients, especially young children, blood pressure may not decrease until significant shock has already occurred, making it a late indicator of inadequate perfusion. Depending solely on systolic blood pressure to evaluate perfusion status in this age group can lead to a delay in appropriate interventions. Distal capillary refill time, skin color, and temperature changes, and the presence of peripheral pulses are more sensitive and early indicators of perfusion status in pediatric patients. Monitoring distal capillary refill provides information on peripheral perfusion, while changes in skin color and temperature can signal circulatory compromise. Evaluating the presence or absence of peripheral pulses offers insights into vascular perfusion. These parameters offer more reliable and prompt feedback on a child's perfusion status compared to systolic blood pressure.

2. Parents of a sick infant talk with a nurse about their baby. One parent says, “I am so upset; I didn’t realize our baby was ill.” What major indication of illness in an infant should the nurse explain to the parent?

• A. Grunting respirations
• B. Excessive perspiration
• C. Longer periods of sleep
• D. Crying immediately after feedings

Correct answer: C

Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.

3. A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?

• A. Administering chemotherapy
• B. Preventing infection
• C. Monitoring for signs of bleeding
• D. Providing nutritional support

Correct answer: A

Rationale: The correct answer is A: Administering chemotherapy. In the care of a child with acute lymphoblastic leukemia (ALL), the priority nursing intervention is administering chemotherapy. Chemotherapy is the primary treatment for ALL and plays a crucial role in managing the disease. While preventing infection, monitoring for signs of bleeding, and providing nutritional support are important aspects of caring for a child with ALL, administering chemotherapy takes precedence as it directly targets the cancer cells and aims to induce remission.

4. The nurse is reviewing the laboratory test results of a child diagnosed with disseminated intravascular coagulation (DIC). What would the nurse interpret as indicative of this disorder?

• A. Shortened prothrombin time
• B. Increased fibrinogen level
• C. Positive fibrin split products
• D. Increased platelets

Correct answer: C

Rationale: Positive fibrin split products are indicative of disseminated intravascular coagulation (DIC). In DIC, there is widespread clotting and subsequent consumption of clotting factors, leading to the formation of fibrin split products. A shortened prothrombin time (Choice A) is not typically seen in DIC as it indicates faster clotting, which is opposite to the pathophysiology of DIC. An increased fibrinogen level (Choice B) may be observed in the early stages of DIC due to the compensatory increase in production, but it is not a definitive indicator. Increased platelets (Choice D) may be seen in the early stages of DIC due to the body's attempt to compensate for clot formation, but it is not a specific finding for DIC.

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.

Similar Questions