Nursing Elites

1. A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:

• A. Sleep Pattern Disturbance related to pain.
• B. Pain related to ear infection.
• C. Altered Family Processes related to ill child.
• D. Ineffective Thermoregulation Related to Infection

Correct answer: B

Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.

2. The instructor is teaching a group of new mothers about infant care. Which statement indicates that further teaching is needed?

• A. I should put my baby to sleep on their back.
• B. I can give my baby water if they seem thirsty.
• C. Breastfeeding provides all the nutrients my baby needs.
• D. I should burp my baby after each feeding.

Correct answer: B

Rationale: The correct answer is B. Newborns do not need additional water as breast milk or formula provides all the necessary hydration. Giving water to infants can be harmful and is not recommended as it can interfere with the balance of electrolytes in their bodies. Choice A is correct as placing babies on their back for sleep is the recommended safe sleeping position. Choice C is also correct as breastfeeding does provide all the essential nutrients for babies. Choice D is correct as burping the baby after each feeding helps prevent discomfort from trapped air.

3. What is the main cause or association of Type 2 diabetes?

• A. Mostly associated with autoantibodies
• B. Mostly associated with childhood cancer
• C. Commonly associated with obesity and metabolic syndrome
• D. Commonly associated with overeating

Correct answer: C

Rationale: Type 2 diabetes is commonly associated with obesity and metabolic syndrome. These conditions are major contributing factors to the development of Type 2 diabetes due to insulin resistance and other metabolic abnormalities linked to excess body weight and unhealthy lifestyle habits.

4. Your assessment of a 5-year-old child reveals that he is unresponsive with a respiratory rate of 8 breaths/min and a heart rate of 50 beats/min. Treatment for this child should include:

• A. high-flow oxygen via non-rebreathing mask and rapid transport.
• B. assisted ventilation with a bag-mask device and rapid transport.
• C. positive-pressure ventilation, chest compressions, and rapid transport.
• D. back slaps and chest thrusts while attempting artificial ventilations.

Correct answer: C

Rationale: In a 5-year-old child who is unresponsive with severe bradycardia and bradypnea, the priority is to provide positive-pressure ventilation to support breathing and perform chest compressions to support circulation. This child is in cardiac arrest, and the recommended treatment according to pediatric basic life support guidelines involves a combination of positive-pressure ventilation and chest compressions to maintain oxygenation and circulation. Rapid transport to a medical facility for further advanced care is crucial in this critical situation. Choices A, B, and D are incorrect because high-flow oxygen via non-rebreathing mask, assisted ventilation with a bag-mask device, and back slaps with chest thrusts are not sufficient in a cardiac arrest situation where the child requires immediate positive-pressure ventilation and chest compressions to maintain oxygenation and circulation.

5. When working with a new adolescent patient, which greeting by the nurse indicates awareness of the needs of the adolescent client?

• A. I will talk with your parents first, and then you can tell me why you are here.
• B. Please let me know what your concerns are, and if you have any questions.
• C. Before we begin, I will need to know if you are sexually active.
• D. I will do the physical exam first, and then we will talk about your history.

Correct answer: B

Rationale: The greeting 'Please let me know what your concerns are, and if you have any questions.' indicates awareness of the needs of the adolescent client. It encourages open communication, allows the adolescent to voice their concerns, and shows that their questions are welcomed and valued, fostering a trusting nurse-patient relationship. Choices A, C, and D do not prioritize the adolescent's perspective or promote open communication. Asking to talk to the parents first (Choice A) may hinder the adolescent's autonomy and trust. Inquiring about sexual activity (Choice C) may be necessary but should be approached with sensitivity and privacy. Doing the physical exam first (Choice D) before discussing the patient's history may not align with the adolescent's need for communication and understanding.

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