Nursing Elites

1. While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?

• A. The 6-month-old in deep sleep
• B. The 2-year-old who is cooperative when the nurse takes vital signs
• C. The 4-year-old who is actively watching cartoons
• D. The 14-month-old who is screaming and thrashing his arms and legs

Correct answer: D

Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.

2. Parents of a newborn with ambiguous genitalia want to know how long they will have to wait to know whether they have a boy or a girl. The nurse answers the parents based on what knowledge?

• A. Chromosome analysis will be complete in 7 days.
• B. A physical examination will be able to provide a definitive answer.
• C. Additional laboratory testing is necessary to assign the correct gender.
• D. Gender assignment involves collaboration between the parents and a multidisciplinary team.

Correct answer: D

Rationale: Gender assignment in cases of ambiguous genitalia is a complex process that requires a multidisciplinary approach, including genetic, endocrinological, and psychological evaluations. The decision should be made collaboratively with the parents.

3. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

• A. It is best to wait until the child asks about it.
• B. The best time to tell the child is between the ages of 7 and 10 years.
• C. It is not necessary to tell a child who was adopted so young.
• D. Telling the child is an important aspect of their parental responsibilities.

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

4. When assessing a child with chronic renal failure, which clinical manifestations would the nurse expect to find?

• A. Uremic frost
• B. Hypotension
• C. Massive hematuria
• D. Severe metabolic acidosis

Correct answer: A

Rationale: When assessing a child with chronic renal failure, the nurse would expect to find uremic frost as a clinical manifestation. Uremic frost, a white powdery deposit of urea on the skin, occurs in severe cases of chronic renal failure due to the accumulation of urea and other waste products in the blood. Hypotension and massive hematuria are less common in chronic renal failure, while severe metabolic acidosis is typically mild to moderate and not a prominent clinical manifestation.

5. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?

• A. Respiratory rate of 20 breaths per minute
• B. Heart rate of 89 beats per minute
• C. Heart rate of 120 beats per minute
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.

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