Nursing Elites

1. A child with a diagnosis of congenital heart disease is admitted to the hospital. What should the nurse include in the child’s care plan?

• A. Monitoring fluid status
• B. Encouraging activity
• C. Promoting a high-calorie diet
• D. Maintaining oxygen therapy

Correct answer: A

Rationale: Monitoring fluid status is crucial for a child with congenital heart disease because these children are at risk of fluid overload which can worsen their condition. Monitoring fluid intake and output helps prevent complications like congestive heart failure. Encouraging activity (Choice B) should be individualized based on the child's condition and tolerance, as excessive activity can strain the heart. Promoting a high-calorie diet (Choice C) is not typically recommended for children with congenital heart disease unless specifically indicated, as excessive weight gain can worsen their cardiac function. Maintaining oxygen therapy (Choice D) may be necessary in some cases, but monitoring fluid status is a more fundamental aspect of care for children with congenital heart disease.

2. The nurse caring for families in crisis assesses the affective function of an immigrant family consisting of a father, mother, and two school-age children. Based on Friedman's structural functional theory, what defines this family component?

• A. Meeting the love and belonging needs of each member
• B. Teaching children how to function and assume adult roles in society
• C. Ensuring the family has necessary resources with appropriate allocation
• D. Involving the provision of physical care to keep the family healthy

Correct answer: A

Rationale: In Friedman's structural functional theory, the affective function of a family involves meeting the love and belonging needs of each member. This includes emotional support, care, and connections that contribute to the overall well-being of the family unit. Choice B is incorrect as it pertains more to the socialization function of the family, where children learn societal roles. Choice C relates to the economic function of the family, ensuring resources are available and allocated appropriately. Choice D focuses on the instrumental function of the family, which involves meeting the physical needs and health of its members.

3. Parents of a sick infant talk with a nurse about their baby. One parent says, “I am so upset; I didn’t realize our baby was ill.” What major indication of illness in an infant should the nurse explain to the parent?

• A. Grunting respirations
• B. Excessive perspiration
• C. Longer periods of sleep
• D. Crying immediately after feedings

Correct answer: C

Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.

4. Parents of a sick infant talk with a nurse about their baby. One parent says, “I am so upset; I didn’t realize our baby was ill.” What major indication of illness in an infant should the nurse explain to the parent?

• A. Grunting respirations
• B. Excessive perspiration
• C. Longer periods of sleep
• D. Crying immediately after feedings

Correct answer: C

Rationale: Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it may indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, excessive perspiration (choice B) may indicate overheating or fever, and crying immediately after feedings (choice D) can be a sign of gastrointestinal discomfort, such as colic or reflux. However, in this scenario, the emphasis is on changes in sleep patterns as a potential indicator of illness.

5. What is the priority nursing responsibility when a 3-year-old child in a crib is experiencing a tonic-clonic seizure with a clamped jaw?

• A. Apply restraints.
• B. Administer oxygen.
• C. Protect the child from self-injury.
• D. Insert a plastic airway in the child’s mouth.

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints (Choice A) can cause harm by restricting movement during the seizure. While administering oxygen (Choice B) may be necessary, it is not the immediate priority during an active seizure. Inserting a plastic airway (Choice D) is contraindicated as it can lead to injury and is not recommended during a seizure. Protecting the child from self-injury (Choice C) is crucial to prevent harm from uncontrolled movements and potential falls, ensuring the safety of the child.

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