Nursing Elites

1. A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?

• A. Refer him for immediate medical evaluation
• B. Administer analgesics and recommend scrotal support.
• C. Apply an ice bag and observe for increasing pain.
• D. Reassure the adolescent that occasional pain is common with the changes of puberty.

Correct answer: A

Rationale: Sudden and severe scrotal pain in an adolescent male is a medical emergency and may indicate testicular torsion, which requires immediate evaluation and intervention to prevent testicular loss.

2. Which reflex is expected to disappear by 4 months of age?

• A. Rooting reflex
• B. Moro reflex
• C. Babinski reflex
• D. Palmar grasp

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, typically disappears by 4 months as the infant's nervous system matures. This reflex is important for assessing the development of the nervous system in newborns. The Rooting reflex (Choice A) is related to turning the head in response to cheek stimulation; the Babinski reflex (Choice C) involves the fanning of toes in response to foot stimulation; and the Palmar grasp (Choice D) is the curling of the fingers around an object placed in the infant's hand. These reflexes have different timelines for disappearance and are not typically expected to be gone by 4 months of age.

3. Which describe the feelings and behaviors of adolescents related to divorce? (Select all that apply.)

• A. Disturbed concept of sexuality
• B. All are applicable
• C. Worry about themselves, parents, or siblings
• D. Expression of anger, sadness, shame, or embarrassment

Correct answer: B

Rationale: Adolescents may withdraw from social interactions, worry about the impact of the divorce, and express strong emotions such as anger or sadness.

4. 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.

5. Apgar scoring is conducted at 1 minute and 5 minutes after birth. It is used to determine:

• A. Major body systems’ responses at birth
• B. Future intelligence of the newborn
• C. Level of parent and newborn interaction
• D. Gestational age of the newborn

Correct answer: A

Rationale: The Apgar score assesses a newborn's physical condition immediately after birth by evaluating heart rate, respiratory effort, muscle tone, reflex response, and color. Therefore, the correct answer is A. The other choices are incorrect because B) the Apgar score does not predict future intelligence, C) it does not measure parent and newborn interaction, and D) it is not used to determine gestational age.

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