Nursing Elites

1. What should the nurse include in the discharge teaching for a 3-year-old child diagnosed with acute otitis media?

• A. Encourage the child to drink plenty of fluids
• B. Encourage the child to eat a balanced diet
• C. Administer pain medication as needed
• D. Apply warm compresses to the affected ear

Correct answer: A

Rationale: The correct answer is to encourage the child to drink plenty of fluids. This helps to relieve symptoms and prevent dehydration in children with acute otitis media. Encouraging a balanced diet is important for overall health but may not directly impact otitis media symptoms. While administering pain medication as needed can help manage discomfort, it is not a primary discharge teaching for this condition. Applying warm compresses to the affected ear is not typically recommended in acute otitis media cases as it can potentially worsen the infection.

2. A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and it was positive. She adds that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl if she has told this to anyone, she replies, 'Yes, but my mother doesn’t believe me.' Legally, who should the nurse notify?

• A. Police regarding a possible sex crime
• B. Healthcare provider to confirm the pregnancy
• C. Child Protective Services for immediate intervention
• D. Girl’s mother about the positive pregnancy test result

Correct answer: C

Rationale: In this scenario, the nurse should notify Child Protective Services for immediate intervention. The girl disclosed ongoing sexual abuse by her grandfather, which is a serious concern requiring immediate protection and intervention by the appropriate authorities. Child Protective Services are trained to handle cases of child abuse and neglect, ensuring the safety and well-being of the child. While notifying the police about a possible sex crime is crucial, Child Protective Services should be the first point of contact in cases of suspected child abuse due to their specialized role. Confirming the pregnancy through a healthcare provider is not the priority at this moment, as ensuring the safety of the child is paramount. Informing the girl's mother about the positive test result is not appropriate given the lack of belief in the abuse disclosure and the potential risk to the child's safety.

3. A 5-year-old child with a diagnosis of asthma is being evaluated for medication management. What is an important assessment for the nurse to perform?

• A. Assess the child's sleep patterns
• B. Assess the child's dietary intake
• C. Assess the child's academic performance
• D. Assess the child's behavior at home

Correct answer: B

Rationale: Assessing the child's dietary intake is crucial in managing asthma as certain foods can trigger symptoms or exacerbate the condition. Monitoring the child's diet can help identify triggers, ensure proper nutrition, and support the child's overall health. Assessing sleep patterns (Choice A) may be relevant but is not as directly linked to asthma management as dietary intake. Academic performance (Choice C) and behavior at home (Choice D) are important aspects of a child's well-being but are not directly related to asthma management.

4. During a clinical conference with a group of nursing students, the instructor is describing burn classification. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?

• A. Skin that is reddened, dry, and slightly swollen
• B. Skin appearing wet with significant pain
• C. Skin with blistering and swelling
• D. Skin that is leathery and dry with some numbness

Correct answer: D

Rationale: Full-thickness burns are characterized by a leathery, dry appearance with numbness due to nerve damage. Choice A describes characteristics of superficial burns, which are not full-thickness. Choice B describes characteristics of partial-thickness burns with intact blisters, not full-thickness burns. Choice C describes characteristics of partial-thickness burns with blistering and swelling, not full-thickness burns.

5. Why should the nurse closely monitor the IV flow rate for a 5-month-old infant with severe diarrhea receiving IV fluids?

• A. Limiting output
• B. Replacing lost fluids
• C. Avoiding IV infiltration
• D. Preventing cardiac overload

Correct answer: D

Rationale: The correct answer is D: Preventing cardiac overload. Infants are highly vulnerable to fluid overload, making it essential to carefully monitor IV flow rates to prevent complications such as cardiac overload. Rapid administration of IV fluids can lead to an excessive increase in circulating volume, potentially causing cardiac strain or heart failure in infants. Choices A, B, and C are incorrect. Monitoring the IV flow rate is not primarily aimed at limiting output, replacing lost fluids, or avoiding IV infiltration in this scenario. The key concern is to prevent the risk of cardiac overload due to the infant's susceptibility to fluid imbalances.

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