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. The mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic occurrence is most likely responsible for the presenting signs?

• A. Gastrointestinal perforation may have occurred.
• B. The object may have been aspirated.
• C. The object may be lodged in the esophagus.
• D. The object may be embedded in the stomach wall.

Correct answer: C

Rationale: The symptoms of gagging and drooling suggest that the foreign object is likely lodged in the esophagus. This can cause significant discomfort and potential complications, requiring immediate medical evaluation.

3. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?

• A. Explain that it will not be painful.
• B. Suggest to him that he not worry about losing just a little bit of blood.
• C. Discuss with him how his body is always in the process of making blood.
• D. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.

Correct answer: C

Rationale: Discussing how the body continuously makes blood helps the child understand that losing a small amount is normal and not harmful. This educational approach also helps reduce anxiety by giving the child a sense of control over the situation.

4. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session?

• A. Overeating
• B. All are applicable
• C. Frequent burping
• D. Parental smoking

Correct answer: B

Rationale: Overeating, swallowing excessive air (leading to frequent burping), and parental smoking are known to contribute to colic in infants. Understimulation is not typically associated with colic.

5. By what age does birth weight usually triple?

• A. 1 year
• B. 1 month
• C. 2 years
• D. 6 months

Correct answer: A

Rationale: The correct answer is A: 1 year. By the age of 1 year, a baby’s birth weight typically triples. This period allows for significant growth and development in infants. Choices B, C, and D are incorrect because birth weight does not usually triple by 1 month, 2 years, or 6 months of age, respectively.

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