Nursing Elites

1. A child with a diagnosis of diabetes insipidus is admitted to the hospital. What is the priority nursing intervention?

• A. Administering insulin
• B. Monitoring fluid balance
• C. Administering diuretics
• D. Monitoring vital signs

Correct answer: B

Rationale: The correct priority nursing intervention for a child diagnosed with diabetes insipidus is to monitor fluid balance. Diabetes insipidus is a condition characterized by excessive urination and thirst, which can lead to dehydration. Monitoring fluid balance is essential to prevent dehydration and ensure the child's hydration status remains stable. Administering insulin (Choice A) is not indicated in diabetes insipidus because it is a disorder of the posterior pituitary gland, not the pancreas. Administering diuretics (Choice C) would exacerbate fluid loss in a child already at risk for dehydration. Monitoring vital signs (Choice D) is important but not the priority when compared to maintaining fluid balance in a child with diabetes insipidus.

2. On the third day of hospitalization, the nurse observes that a 2-year-old toddler who had been screaming and crying inconsolably begins to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?

• A. Denial
• B. Despair
• C. Mistrust
• D. Rejection

Correct answer: B

Rationale: The correct answer is B: 'Despair'. In separation anxiety, the stage of despair is characterized by regression and withdrawal after the initial protest. The toddler's shift from intense crying to lying quietly with a blanket demonstrates this withdrawal behavior. Choice A, 'Denial', is incorrect as denial involves refusing to accept the reality of separation. Choice C, 'Mistrust', is incorrect as it relates to a lack of trust rather than the stage of separation anxiety described in the scenario. Choice D, 'Rejection', is incorrect as it does not reflect the behavior of the toddler in the scenario, which is more indicative of withdrawal and regression.

3. A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?

• A. Administering chemotherapy
• B. Preventing infection
• C. Monitoring for signs of bleeding
• D. Providing nutritional support

Correct answer: A

Rationale: The correct answer is A: Administering chemotherapy. In the care of a child with acute lymphoblastic leukemia (ALL), the priority nursing intervention is administering chemotherapy. Chemotherapy is the primary treatment for ALL and plays a crucial role in managing the disease. While preventing infection, monitoring for signs of bleeding, and providing nutritional support are important aspects of caring for a child with ALL, administering chemotherapy takes precedence as it directly targets the cancer cells and aims to induce remission.

4. 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.

5. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant’s abdomen?

• A. A distended colon
• B. Marked tenderness around the umbilicus
• C. An olive-sized mass in the right upper quadrant
• D. Rhythmic peristaltic waves in the lower abdomen

Correct answer: C

Rationale: When palpating the abdomen of an infant with hypertrophic pyloric stenosis (HPS), the nurse would expect to feel an olive-sized mass in the right upper quadrant. This finding is characteristic of HPS, where the hypertrophied pyloric muscle forms a palpable mass in the abdomen. Choices A, B, and D are incorrect. A distended colon is not a typical finding in HPS, marked tenderness around the umbilicus is not specific to this condition, and rhythmic peristaltic waves in the lower abdomen are not associated with HPS.

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