Nursing Elites

1. A 12-year-old male is brought to the clinic after falling during a skateboarding trick. The child's vital signs are heart rate 135 beats/minute, respirations 20 breaths/minute, and blood pressure 90/60. Which finding should the practical nurse report to the healthcare provider immediately?

• A. The client complains of his back being sore.
• B. Capillary refill is less than 2 seconds.
• C. Blood pressure is 94/68.
• D. Peripheral pulses are weak and rapid.

Correct answer: D

Rationale: In this scenario, the 12-year-old male with a heart rate of 135 beats/minute, respirations of 20 breaths/minute, and blood pressure of 90/60 after falling during a skateboarding trick exhibits signs of shock. Weak and rapid peripheral pulses are concerning as they may indicate decreased cardiac output and tissue perfusion, which are signs of shock. This finding should be reported to the healthcare provider immediately for further evaluation and intervention to prevent potential complications. The other choices are less urgent. Complaints of back soreness (choice A) could be related to musculoskeletal injury. Capillary refill less than 2 seconds (choice B) is within the normal range, indicating adequate peripheral perfusion. A blood pressure of 94/68 (choice C) is slightly higher than the initial reading and may be compensatory in response to the fall and shock state.

2. A toddler with a chronic illness that requires frequent hospitalization is likely to experience which psychosocial developmental challenge?

• A. Fixation with feelings of inadequacy
• B. Interference with the development of autonomy
• C. Distortion of differentiation of self from parent
• D. Delayed language, fine-motor, and self-care skills

Correct answer: B

Rationale: Toddlers with chronic illnesses requiring frequent hospitalization may experience interference with the development of autonomy. This is because the need for constant medical care can restrict their independence and ability to explore and make choices, which are essential aspects of achieving autonomy according to Erikson's stages of psychosocial development. Choices A, C, and D are incorrect. Fixation with feelings of inadequacy (Choice A) is more commonly associated with Erikson's stage of industry vs. inferiority in middle childhood. Distortion of differentiation of self from parent (Choice C) is related to the separation-individuation phase of Mahler's theory of object relations, typically occurring in infancy. Delayed language, fine-motor, and self-care skills (Choice D) may be impacted by chronic illness but are not the primary psychosocial developmental challenge faced by toddlers in this context.

3. The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first?

• A. Girls between ages 10 and 14.
• B. Boys between ages 10 and 14.
• C. Boys and girls between 12 and 14.
• D. Boys and girls between 8 and 12.

Correct answer: A

Rationale: Corrected Question: The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first? Girls between ages 10 and 14 are at the highest risk for scoliosis and should be screened first as they have a higher incidence of developing scoliosis during their adolescent growth spurt. Early detection and intervention can help prevent further complications associated with scoliosis. Boys between ages 10 and 14 (choice B) are not at the highest risk compared to girls in the same age group. Boys and girls between 12 and 14 (choice C) are at a lower risk compared to girls between ages 10 and 14. Boys and girls between 8 and 12 (choice D) are at a lower risk group compared to girls between ages 10 and 14.

4. While assessing the vital signs of a 10-year-old who underwent a tonsillectomy this morning, the nurse observes the child swallowing every 2-3 minutes. Which assessment should the nurse implement?

• A. Inspect the posterior oropharynx
• B. Assess for teeth clenching or grinding
• C. Touch the tonsillar pillars to stimulate the gag reflex
• D. Ask the child to speak to evaluate a change in voice tone

Correct answer: A

Rationale: Frequent swallowing post-tonsillectomy may indicate bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or clots, which may necessitate immediate intervention. Option B is incorrect as teeth clenching or grinding is not directly related to the observation of frequent swallowing in this scenario. Option C is incorrect because stimulating the gag reflex is not necessary at this point and may be uncomfortable for the child. Option D is incorrect as evaluating a change in voice tone is not relevant to the situation of observing frequent swallowing.

5. What response should the practical nurse (PN) provide when a school-age child asks to talk with a dying sister?

• A. Talk loudly to ensure the dying person hears and recognizes others' voices.
• B. Touch can provide a tactile presence if the dying person does not respond to words.
• C. Sitting close offers the dying person the sensation of others' presence.
• D. Although the dying person may not respond, they can still hear what is said.

Correct answer: D

Rationale: The correct response is D because it is believed that hearing is the last sense to go. Even if the dying person does not respond, speaking to them can still provide comfort. Choice A is incorrect because talking loudly is not necessary and can be distressing. Choice B is incorrect as it focuses on touch rather than the sense of hearing. Choice C is incorrect because sitting close may not necessarily help the dying person hear better.

Similar Questions