Nursing Elites

1. A 2-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What should the nurse do first?

• A. Ask the parents about the child’s speech development
• B. Perform a hearing test
• C. Inspect the child’s ears for drainage
• D. Refer the child to an audiologist

Correct answer: C

Rationale: The most appropriate initial action for the nurse to take is to inspect the child's ears for drainage. This step can provide immediate information on the presence of infection or fluid, which could be impacting the child's hearing. By assessing for drainage, the nurse can gather valuable initial data to determine the next course of action, such as further evaluation or treatment. Asking about speech development or referring to an audiologist would be secondary steps after assessing the physical condition of the ears. Performing a hearing test would also be premature without first examining the ears for any visible issues.

2. In a 7-year-old child with a history of asthma experiencing an acute asthma exacerbation and displaying wheezing and the use of accessory muscles to breathe, what is the nurse’s priority intervention?

• A. Administer a nebulized bronchodilator
• B. Obtain an arterial blood gas
• C. Start the child on oxygen therapy
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to administer a nebulized bronchodilator. During an acute asthma exacerbation in a child with wheezing and increased work of breathing, the priority intervention is to provide immediate bronchodilation to dilate the airways, relieve bronchospasm, and improve breathing. This intervention aims to manage the acute asthma attack effectively and prevent further respiratory distress. Obtaining an arterial blood gas, starting oxygen therapy, or notifying the healthcare provider are important actions, but administering a bronchodilator takes precedence in addressing the acute respiratory compromise.

3. When assessing a child with suspected meningitis, which finding is a characteristic sign of meningitis?

• A. High-pitched cry
• B. Tachycardia
• C. Photophobia
• D. Hypotension

Correct answer: C

Rationale: Photophobia, which is sensitivity to light, is a characteristic sign of meningitis in children. It commonly presents along with symptoms such as headache and neck stiffness. This symptom is important to recognize early for prompt diagnosis and treatment of meningitis.

4. When a 3-year-old boy asks a nurse why his baby sister is eating his mommy’s breast, how should the nurse respond? (Select the response that does not apply.)

• A. Remind him that his mother breastfed him too
• B. Clarify that breastfeeding is the mother’s choice
• C. Reassure the older brother that it does not hurt his mother
• D. Explain that newborns get milk from their mothers in this way

Correct answer: A

Rationale: In this scenario, the nurse should avoid reminding the older sibling about his own breastfeeding experience as it does not directly address the question posed by the boy. Providing simple explanations about breastfeeding and newborn feeding patterns helps the older sibling understand the natural process without bringing up personal experiences. Choice B is correct because clarifying that breastfeeding is the mother's choice helps the older sibling understand the concept of personal decisions. Choice C is appropriate as reassuring the older brother that it does not hurt his mother addresses a common concern children may have. Choice D is also suitable as it explains in simple terms how newborns receive milk from their mothers.

5. What is the best response for the nurse when a 2-year-old boy begins to cry as the mother starts to leave?

• A. Let me read this book to you.
• B. Two-year-olds usually stop crying the minute the parent leaves.
• C. Now be a big boy. Mommy will be back soon.
• D. Let's wave bye-bye to mommy.

Correct answer: D

Rationale: The best response for the nurse in this situation is to help the child understand that the separation is temporary. Waving bye-bye to mommy can be reassuring to the child and make the separation process easier. It acknowledges the child's feelings while providing a positive and comforting interaction. Choice A may distract the child temporarily but doesn't address the underlying issue of separation anxiety. Choice B is inaccurate as children may continue to cry even after the parent leaves. Choice C diminishes the child's emotions and doesn't offer a supportive approach.

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