Nursing Elites

1. A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 to 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?

• A. Bilateral bronchial breath sounds.
• B. Diaphragmatic respiration.
• C. A resting respiratory rate of 35 breaths per minute.
• D. Flaring of the nares.

Correct answer: D

Rationale: Flaring of the nares is a clinical sign of acute respiratory distress in infants. It indicates an increased effort to breathe and is a crucial finding that requires immediate attention, as it signifies the child is having difficulty breathing and may be in respiratory distress. Choices A, B, and C are incorrect. Bilateral bronchial breath sounds may be present in conditions like pneumonia but do not specifically indicate acute respiratory distress. Diaphragmatic respiration is a normal breathing pattern and not a sign of distress. A resting respiratory rate of 35 breaths per minute in a 4-month-old infant is within the expected range, so it does not necessarily indicate acute respiratory distress.

2. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

• A. The mother is a single parent and lives with her parents
• B. The mother states the baby is irritable during feedings
• C. The infant’s formula has been changed twice
• D. The diaper area shows severe skin breakdown

Correct answer: D

Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.

3. The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?

• A. Use of protective barriers during sexual activity prevents most strains of HPV infection
• B. Most adolescents are not honest about being sexually active
• C. Not all strains of HPV will be covered if given at a later date
• D. Immunity must be established to prevent future HPV infection and the risk for cervical cancer

Correct answer: D

Rationale: Administering the HPV vaccine at this visit is essential to establish immunity against HPV, thus reducing the risk of HPV infection and cervical cancer. Vaccination is a proactive measure to protect the adolescent's health in the future. Choice A is incorrect because although protective barriers can reduce the risk of HPV transmission, the vaccine provides broader protection. Choice B is incorrect as it makes a generalization about adolescent behavior that is not relevant to vaccination. Choice C is incorrect as it suggests that delaying vaccination would not impact coverage, which is inaccurate as earlier vaccination provides broader protection against HPV strains.

4. In a 12-year-old child with a history of epilepsy brought to the emergency department after experiencing a 10-minute seizure, what is the nurse’s priority intervention?

• A. Administer oxygen
• B. Administer antiepileptic medication as prescribed
• C. Monitor the child’s vital signs
• D. Check the child’s blood glucose level

Correct answer: B

Rationale: Administering antiepileptic medication as prescribed is the priority intervention in a child with a history of epilepsy who experienced a prolonged seizure. This action is crucial to stop the seizure and prevent further complications associated with prolonged seizure activity. Administering oxygen may be necessary, but the priority is to stop the seizure. Monitoring vital signs and checking blood glucose levels are important but secondary to administering antiepileptic medication to manage the seizure.

5. A child with sickle cell anemia is being treated for a vaso-occlusive crisis. Which intervention should the practical nurse (PN) implement?

• A. Apply cold packs to painful areas.
• B. Encourage increased fluid intake.
• C. Administer high doses of vitamin C.
• D. Provide low-calorie meals.

Correct answer: B

Rationale: Encouraging increased fluid intake is crucial in managing vaso-occlusive crises in patients with sickle cell anemia. Dehydration can worsen these crises, so adequate hydration is essential to prevent complications and improve outcomes. Applying cold packs to painful areas may exacerbate vaso-occlusive crises by causing vasoconstriction. Administering high doses of vitamin C is not directly indicated for vaso-occlusive crises in sickle cell anemia. Providing low-calorie meals is not the priority during a vaso-occlusive crisis; maintaining adequate nutrition is important, but hydration takes precedence in this situation.

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