Nursing Elites

1. A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?

• A. Monitoring for signs of infection
• B. Providing nutritional support
• C. Monitoring for signs of bleeding
• D. Monitoring for signs of pain

Correct answer: A

Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, increasing the risk of infections. Detecting and managing infections promptly is crucial to prevent complications and improve outcomes. Providing nutritional support is important, but infection prevention takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of bleeding is relevant in leukemia due to decreased platelet count, but infection surveillance is more critical. Monitoring for signs of pain is essential, but addressing infections promptly is the priority to prevent further deterioration in the child's condition.

2. 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.

3. A child has undergone a tonsillectomy, and a nurse is providing postoperative care. What is an important nursing intervention?

• A. Encouraging deep breathing exercises
• B. Encouraging the child to eat
• C. Administering antibiotics
• D. Applying ice to the throat

Correct answer: C

Rationale: Administering antibiotics is a crucial nursing intervention after a tonsillectomy because it helps prevent infections, which are a common postoperative complication. Encouraging deep breathing exercises (Choice A) is also important for promoting lung expansion and preventing respiratory complications. Encouraging the child to eat (Choice B) may not be appropriate immediately after a tonsillectomy due to the risk of throat irritation and discomfort. Applying ice to the throat (Choice D) is generally not recommended post-tonsillectomy as it may cause vasoconstriction and hinder the healing process.

4. During a physical examination of a 9-month-old baby, the nurse observes a flat, discolored area on the skin. The nurse documents this as a:

• A. Papule.
• B. Macule.
• C. Vesicle.
• D. Scale.

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a flat, discolored area on the skin that is smaller than 1 cm in diameter. This term is used to describe conditions like freckles or petechiae. Choice A, Papule, refers to a small, solid, raised skin lesion (<0.5 cm) like a pimple. Choice C, Vesicle, describes a small blister filled with clear fluid. Choice D, Scale, refers to flakes or plates of dead skin that may be dry or greasy.

5. Which of the following signs or symptoms is more common in children than adults following head trauma?

• A. nausea and vomiting
• B. altered mental status
• C. tachycardia and diaphoresis
• D. changes in pupillary reaction

Correct answer: A

Rationale: Nausea and vomiting are more common in children following head trauma due to their higher risk of increased intracranial pressure. Children have less skull compliance and higher brain water content, making them more susceptible to developing symptoms like nausea and vomiting. Altered mental status (choice B) can occur in both children and adults but is not more common in children. Tachycardia and diaphoresis (choice C) are nonspecific and can occur in both age groups. Changes in pupillary reaction (choice D) are not typically more common in children following head trauma compared to adults.

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