Nursing Elites

1. A 3-year-old child is admitted to the hospital with a diagnosis of Kawasaki disease. What is the priority nursing intervention?

• A. Administering IV immunoglobulin
• B. Monitoring for coronary artery aneurysms
• C. Encouraging fluid intake
• D. Providing nutritional support

Correct answer: B

Rationale: The priority nursing intervention for a 3-year-old child with Kawasaki disease is monitoring for coronary artery aneurysms. Kawasaki disease can lead to the development of coronary artery aneurysms, which are one of the most serious complications of the disease. Early detection and monitoring of coronary artery changes are essential for prompt intervention and prevention of adverse outcomes. Administering IV immunoglobulin is an important treatment for Kawasaki disease, but monitoring for coronary artery aneurysms takes precedence as it directly impacts the child's long-term prognosis. Encouraging fluid intake and providing nutritional support are important aspects of care but are not the priority when compared to monitoring for potential life-threatening complications.

2. A parent receives a note from the school that a student in class has head lice. The parent calls the school nurse to ask how to check for head lice. What instructions should the nurse provide?

• A. Ask the child where it itches.
• B. Check to see if your dog has ear mites.
• C. Look along the scalp line for white dots.
• D. Observe between the fingers for red lines.

Correct answer: C

Rationale: The correct answer is to look along the scalp line for white dots (nits) when checking for head lice. White dots are indicative of head lice infestation. Itching alone, as mentioned in choice A, is not a reliable indicator of head lice. Choice B is irrelevant as it refers to checking for ear mites in a dog, not head lice in a human. Observing between the fingers for red lines, as in choice D, is not a method to check for head lice.

3. A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) is made and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?

• A. Place the infant in a warm, dry environment.
• B. Allow parents and siblings to visit.
• C. Maintain standard and contact precautions.
• D. Administer prescribed antibiotics immediately.

Correct answer: C

Rationale: The correct answer is to maintain standard and contact precautions. RSV is highly contagious, primarily spreading through respiratory secretions. Therefore, it is crucial to implement infection control measures to prevent the spread of the virus within the healthcare setting. Option A is incorrect as warmth and dryness are not the primary concern in RSV management. While family support is important, allowing visits may increase the risk of spreading the infection, making option B less appropriate. Option D is incorrect because RSV is a viral infection, and antibiotics are not effective against viruses.

4. A parent receives a note from the school that a student in class has head lice. The parent calls the school nurse to ask how to check for head lice. What instructions should the nurse provide?

• A. Ask the child where it itches.
• B. Check to see if your dog has ear mites.
• C. Look along the scalp line for white dots.
• D. Observe between the fingers for red lines.

Correct answer: C

Rationale: The correct answer is to look along the scalp line for white dots (nits) when checking for head lice. White dots/nits are the eggs of head lice and are commonly found attached to the hair shaft near the scalp. This method helps identify if head lice are present. Choice A is incorrect as itching alone may not be a definitive sign of head lice; it could be due to other reasons. Choice B is irrelevant as ear mites in dogs are not related to head lice infestation in humans. Choice D is also incorrect as observing between the fingers for red lines is not a method for checking head lice.

5. The nurse is developing a plan of care for a 7-year-old boy with diabetes insipidus. What is the priority nursing diagnosis?

• A. Deficient fluid volume related to dehydration
• B. Excess fluid volume related to edema
• C. Deficient knowledge related to fluid intake regimen
• D. Imbalanced nutrition related to excess weight

Correct answer: A

Rationale: The priority nursing diagnosis for a 7-year-old boy with diabetes insipidus is deficient fluid volume related to dehydration. Diabetes insipidus causes excessive thirst and urination, leading to fluid imbalance and potential dehydration. Choice B, excess fluid volume related to edema, is not a priority as diabetes insipidus is characterized by fluid loss, not retention. Choice C, deficient knowledge related to fluid intake regimen, may be important but is not the priority when the child is at risk of dehydration. Choice D, imbalanced nutrition related to excess weight, is not directly associated with the primary concern of fluid volume imbalance in diabetes insipidus.

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