Nursing Elites

1. A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?

• A. Hypotonia and muscle instability
• B. Hypertonia and persistence of primitive reflexes
• C. Tremors and exaggerated posturing
• D. Hemiplegia and hypertonia

Correct answer: A

Rationale: In ataxic cerebral palsy, the characteristic features include hypotonia (low muscle tone) and muscle instability. These manifestations contribute to the infant's difficulty in achieving independent sitting. Hypertonia (increased muscle tone) and persistence of primitive reflexes, as mentioned in option B, are more commonly associated with other types of cerebral palsy like spastic CP. Tremors and exaggerated posturing (option C) are not typical features of ataxic CP. Hemiplegia (paralysis of one side of the body) and hypertonia (increased muscle tone) mentioned in option D are more commonly seen in other types of cerebral palsy, such as spastic CP.

2. A nurse administers naloxone (Narcan) to a post-op patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication?

• A. Drowsiness
• B. Tics and tremors
• C. Increased Pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Naloxone reverses the effects of narcotics. Although the patient�s respiratory status will improve after administration of naloxone, the pain will be more acute.

3. A healthcare professional is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old child. Which of the following findings is a contraindication to the administration of this vaccine?

• A. Family history of egg allergy
• B. Currently taking antibiotics
• C. History of asthma
• D. Presence of rhinorrhea

Correct answer: B

Rationale: Taking antibiotics is a contraindication to receiving the MMR vaccine because antibiotics can potentially interfere with the effectiveness of the vaccine. It is essential to avoid administering the MMR vaccine while the child is on antibiotics to ensure the vaccine provides the intended protection.

4. A parent of a child with celiac disease is receiving teaching from a nurse. Which of the following statements should the nurse make?

• A. You should give your child vitamin supplements that contain iron.
• B. Your child will need a gluten-free diet.
• C. Your child should consume large amounts of dietary fiber.
• D. Your child can resume eating whole wheat bread.

Correct answer: B

Rationale: The correct answer is B. Celiac disease requires a strict gluten-free diet to manage the condition effectively. Gluten-containing foods like wheat, barley, and rye must be avoided to prevent intestinal damage and symptoms in individuals with celiac disease. Therefore, the nurse should emphasize the importance of a gluten-free diet to the parent of the child with celiac disease.

5. When planning care for a pediatric client diagnosed with bacterial meningitis, what is the priority nursing diagnosis?

• A. Impaired Gas Exchange
• B. Risk for Infection
• C. Anxiety (parental)
• D. Acute Pain

Correct answer: A

Rationale: The priority nursing diagnosis when caring for a pediatric client with bacterial meningitis is 'Impaired Gas Exchange.' This diagnosis takes precedence due to the potential for respiratory complications associated with the condition. Bacterial meningitis can lead to increased intracranial pressure, compromising the child's ability to ventilate adequately. Therefore, monitoring and addressing any signs of respiratory distress are crucial in the care of these patients.

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