Nursing Elites

1. A 2-year-old child with a diagnosis of autism spectrum disorder is being discharged. What should the nurse include in the discharge teaching?

• A. Maintain a structured routine
• B. Encourage social interaction
• C. Use positive reinforcement
• D. Use a communication board

Correct answer: A

Rationale: The correct answer is to maintain a structured routine. Children with autism spectrum disorder benefit from a structured routine as it provides them with stability and predictability, which can help reduce anxiety and improve behavior management. Encouraging social interaction (Choice B) may not be suitable for all children with autism, as some may struggle with social skills. While positive reinforcement (Choice C) is a helpful strategy, maintaining a structured routine is more essential for overall management in children with autism spectrum disorder. Using a communication board (Choice D) may be beneficial for communication, but establishing a structured routine is a foundational strategy that should be prioritized in the discharge teaching for a child with autism spectrum disorder.

2. When caring for a neonate with a suspected tracheoesophageal fistula, what nursing care should be included?

• A. Elevating the head but giving nothing by mouth
• B. Elevating the head for feedings
• C. Feeding glucose water only
• D. Avoiding suctioning unless the infant is cyanotic

Correct answer: A

Rationale: In a neonate with a suspected tracheoesophageal fistula, elevating the head but giving nothing by mouth is crucial to prevent aspiration. Placing the neonate in a semi-upright position helps reduce the risk of reflux and aspiration of gastric contents into the lungs. Elevating the head for feedings (Choice B) would still pose a risk of aspiration as the neonate may aspirate during feeding. Feeding glucose water only (Choice C) is not appropriate and does not address the risk of aspiration associated with a tracheoesophageal fistula. Avoiding suctioning unless the infant is cyanotic (Choice D) is incorrect because suctioning may be necessary for maintaining airway patency, regardless of cyanosis, in a neonate with a suspected tracheoesophageal fistula.

3. A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the health care provider?

• A. Fat-free
• B. Protein-enriched
• C. Phenylalanine-free
• D. Low-phenylalanine

Correct answer: D

Rationale: A low-phenylalanine diet is required for infants with PKU to prevent the buildup of phenylalanine, which can lead to brain damage.

4. The nurse volunteering at a homeless shelter to assist families with children identifies homelessness as a risk preventing families from achieving positive outcomes in life. What family theory encompasses this approach to assessing family dynamics?

• A. Duvall's developmental theory
• B. Friedman's structural functional theory
• C. Von Bertalanffy's general system theory applied to families
• D. Resiliency model of family stress, adjustment, and adaptation

Correct answer: D

Rationale: The Resiliency model of family stress, adjustment, and adaptation focuses on identifying the elements of risks and protective factors that help families achieve positive outcomes. In this scenario, the nurse recognizing homelessness as a risk aligns with the resiliency model, which emphasizes how families cope and adapt in the face of stressors. Duvall's theory primarily focuses on family life cycle stages, Friedman's theory emphasizes the roles and functions within a family structure, and Von Bertalanffy's theory looks at families as complex systems rather than specifically addressing resilience in the face of stressors.

5. An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. How should the nurse respond?

• A. It limits the chance of vomiting.
• B. It allows the feeding to be administered rapidly.
• C. The energy that would have been expended on sucking is conserved.
• D. The quantity of nutritional liquid can be regulated better than with a bottle.

Correct answer: C

Rationale: Gavage feedings are necessary for infants with congenital heart defects to conserve the infant's energy by eliminating the need for sucking. This is important because sucking requires energy expenditure, which can be taxing for infants with cardiac defects. Choice A is incorrect as gavage feedings do not primarily limit the chance of vomiting. Choice B is incorrect because the speed of feeding administration is not the primary reason for using gavage feedings in this case. Choice D is incorrect as the regulation of the quantity of nutritional liquid is not the main purpose of gavage feedings in infants with congenital heart defects.

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